RESUMO Contexto: A evidência da regressão espontânea (RE) no carcinoma hepatocelular (CHC) é rara. Objetivo: Revisar todos os casos de RE de CHC em dois centros de referência do Sul do Brasil, destacando as principais características. Métodos: Os dados de todos os pacientes com CHC foram revisados retrospectivamente buscando a ocorrência de RE em pacientes de dois centros terciários do Sul do Brasil, nos últimos 5 anos. O diagnóstico de cirrose foi estabelecido de acordo com dados clínicos, laboratoriais e de imagem, além de endoscopia digestiva alta ou exame histopatológico quando necessário. O diagnóstico de CHC foi baseado em achados típicos de acordo com critérios radiológicos (LIRADS) ou exame histopatológico. A RE foi definida como uma involução parcial ou completa de um CHC na ausência de terapia específica. Resultados: Do total de casos de CHC nos últimos 5 anos (n=433), houve cinco casos de RE. Três (60%) eram homens, a média de idade foi de 62,6 (50,0-76,0) anos, a etiologia foi virus da hepatite C em 3 (60%). A regressão completa foi observada em três pacientes (60%), um paciente (20%) apresentou regressão parcial e um (20%) apresentou recidiva e evoluiu a óbito. O tempo de seguimento variou entre 12 e 21 meses. Nesta apresentação foi destacado um caso (20%) de RE observado após infecção por COVID-19 em paciente com cirrose. Foram revisados os possíveis mecanismos envolvidos nesta situação, enfatizando os mais comuns como hipóxia e imunológicos. Houve também um paciente submetido a procedimento cirúrgico como possível fator envolvido e três pacientes sem fatores de risco evidentes. Conclusão: Este fenômeno possivelmente contribuirá para uma melhor compreensão dos mecanismos fisiopatológicos do CHC. Contexto (RE (CHC rara Objetivo Brasil características Métodos clínicos imagem necessário LIRADS (LIRADS específica Resultados n=433, n433 n n=433 , 433 (n=433) 60% 60 (60% homens 626 62 6 62, 50,076,0 500760 50,0 76,0 50 0 76 (50,0-76,0 60%. . 60%, 20% 20 (20% óbito 1 2 meses COVID19 COVID 19 COVID-1 situação imunológicos evidentes Conclusão n43 n=43 43 (n=433 (60 076 50,076, 50076 500 50, 760 76, 7 (50,0-76, (20 COVID1 COVID- n4 n=4 4 (n=43 (6 07 50,076 5007 (50,0-76 (2 n= (n=4 ( 50,07 (50,0-7 (n= (50,0- (n (50,0 (50, (50 (5

ABSTRACT Background: Spontaneous regression (SR) is defined as the partial or complete disappearance of a tumor, in the absence of a specific treatment. Evidence of the SR in hepatocellular carcinoma (HCC) is rare. Objective: The authors aimed to review all the cases of SR of HCC in two reference centers of Southern Brazil, highlighting the main characteristics. Methods: Data of all patients with HCC were retrospectively reviewed looking for the occurrence of SR in patients from two tertiary centers in Southern Brazil, in the last five years. The diagnosis of cirrhosis was established according to clinical, laboratory and imaging data, as well as upper endoscopy or histopathological examination when necessary. The diagnosis of HCC was based on typical findings according to radiologic criteria (LIRADS) or histopathological examination. Spontaneous regression was defined as a partial or complete involution of a HCC in the absence of a specific therapy. Results: From all cases of HCC in the last 5 years (n=433), there were five cases of SR. Three (60%) were men, the mean age was 62.6 (50.0-76.0) years, and the etiology was HCV in 3 (60%). Complete regression was observed in three patients (60%), one patient (20%) presented partial regression, and one (20%) relapesed and died. The time of follow-up varied between 12 and 21 months. In this presentation, it was highlighted one case of SR observed after COVID-19 infection in a patient with cirrhosis. The possible mechanisms involved in this situation were reviewed, emphasizing the most common like hypoxia and immunological. There were also one patient submitted to a surgical procedure as a possible fator involved and three patients without obvious risk factors. Conclusion: This phenomenon will possibly contribute to a better understanding of the pathophysiological mechanisms of HCC. Background (SR tumor treatment (HCC rare Objective Brazil characteristics Methods clinical data necessary LIRADS (LIRADS therapy Results n=433, n433 n n=433 , 433 (n=433) 60% 60 (60% men 626 62 6 62. 50.076.0 500760 50.0 76.0 50 0 76 (50.0-76.0 60%. . 60%, 20% 20 (20% died followup follow up 1 2 months presentation COVID19 COVID 19 COVID-1 immunological factors Conclusion n43 n=43 43 (n=433 (60 076 50.076. 50076 500 50. 760 76. 7 (50.0-76. (20 COVID1 COVID- n4 n=4 4 (n=43 (6 07 50.076 5007 (50.0-76 (2 n= (n=4 ( 50.07 (50.0-7 (n= (50.0- (n (50.0 (50. (50 (5

RESUMO Trata-se de uma revisão narrativa que visa discutir a importância dos métodos elastográficos na avaliação da hipertensão portal clinicamente significativa (HPCS) em pacientes cirróticos, onde os autores propõem um algoritmo para avaliação desses pacientes. Na doença hepática crônica avançada compensada, o objetivo é prevenir o desenvolvimento de HPCS, e naqueles já com HPCS prevenir o aparecimento de varizes gastroesofágicas (VGE) e outras complicações da hipertensão portal. Na cirrose compensada, a prevalência de VGE é de 30-40% e 10-20% são varizes com risco de sangramento, portanto o uso de métodos não invasivos dispensaria o paciente de endoscopia. A elastografia hepática é um método não invasivo, seguro e reprodutível, disponível através de várias técnicas: elastografia transitória (VCTE), onda de cisalhamento (SWE) e elastografia por ressonância magnética. O Baveno VII apresentou a “regra dos 5” para VCTE: medida da rigidez hepática (LSM) ≤15 kPa e plaquetas >150.000/mm3 excluem HPCS enquanto um LSM ≥25 kPa é altamente sugestivo de HPCS. Além disso, foi proposta a “regra dos 4” para SWE: pacientes com ≥17 kPa podem ser considerados como portadores de HPCS. Por fim, a medição da rigidez do baço (SSM) foi proposta como uma técnica mais específica para prever a presença de HPCS. Em conclusão, a elastografia ganhou prestígio na avaliação não invasiva de pacientes com doença hepática crônica avançada, ao permitir a adoção de medidas profiláticas ao sugerir a presença de HPCS. Tratase Trata se (HPCS cirróticos compensada (VGE 3040% 3040 30 40% 40 30-40 1020% 1020 10 20% 20 10-20 sangramento endoscopia invasivo reprodutível técnicas VCTE, VCTE , (VCTE) SWE (SWE magnética regra 5 (LSM 15 ≤1 150000mm3 mm 150 000 mm3 >150.000/mm 25 ≥2 disso 4 17 ≥1 fim SSM (SSM conclusão 304 3 30-4 102 1 2 10-2 (VCTE ≤ 150000mm 00 ≥ 30- 10- 0

ABSTRACT This is a narrative review that aims to discuss the importance of elastographic methods in the evaluation of clinically significant portal hypertension (CSPH) in cirrhotic patients, where the authors propose an algorithm for evaluating these patients. In compensated advanced chronic liver disease, the goal is to prevent the development of CSPH and, in those already with CSPH, prevent the appearance of gastroesophageal varices (GEV) and other complications of portal hypertension. In compensated cirrhosis, the prevalence of GEV is 30-40%, of which 10-20% are at risk of bleeding. Therefore, using non-invasive methods would exempt the patient from the need of an endoscopy. Hepatic Elastography is a non-invasive, safe, reproducible method, available through many techniques: Vibration-Controlled Transient Elastography (VCTE), Shear Wave Elastography (SWE) and Magnetic Resonance Elastography (MRE). The Baveno VII presented the “rule of 5” for VCTE: liver stiffness measurement (LSM) ≤15 kPa and platelets >150.000/mm3 exclude CSPH, while an LSM ≥25 kPa is highly suggestive of CSPH. Also, the “rule of 4” for SWE has been proposed: patients with ≥17 kPa could be considered as having CSPH. At last, spleen stiffness measurement (SSM) has been proposed as a more specific technique to predict the presence of CSPH. In conclusion, elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH. (CSPH (GEV cirrhosis 3040%, 3040 30 40%, 40 30-40% 1020% 1020 10 20% 20 10-20 bleeding Therefore noninvasive non invasive endoscopy noninvasive, invasive, safe method techniques VibrationControlled Vibration Controlled VCTE, VCTE , (VCTE) (SWE MRE. MRE . (MRE) rule 5 (LSM 15 ≤1 150000mm3 mm 150 000 mm3 >150.000/mm 25 ≥2 Also 4 17 ≥1 last SSM (SSM conclusion 3040% 304 3 40% 30-40 102 1 2 10-2 (VCTE (MRE ≤ 150000mm 00 ≥ 30-4 10- 0 30-

ABSTRACT Direct-acting antivirals are the gold-standard treatment for chronic HCV infections, but few studies have investigated their use on kidney and liver transplant recipients. We conducted a real-world study to evaluate the rates of sustained virological response with direct-acting antivirals in kidney and liver transplant recipients. Moreover, it also aimed to evaluate direct-acting antivirals (DAAs) interference with immunosuppressant levels and to describe the frequency of adverse events. As part of this retrospective observational cohort, we included adult patients that had undergone a kidney transplant (KT) or liver transplant (LT) at our center, had a chronic HCV infection, and were treated with DAAs from June 2016 to December 2021. A total of 165 patients were included in the analysis, divided in 108 KT and 57 LT recipients. HCV genotype 1 was more frequent in KT (58.4%), and genotype 3 was more prevalent in LT (57.9%) patients. Sustained virological response was achieved in 89.6% of patients. Adverse effects were reported by 36% of patients. There were significant interactions with immunosuppressants requiring dose adjustments. A total of three episodes of rejection were reported in KT recipients. In conclusion, DAA treatment resulted in high rates of SVR and was well tolerated in both kidney and liver transplant patients. Adverse events were frequent but not severe in most patients, with low treatment drop-out rates. Interactions with immunosuppressants need monitoring since dose adjustments may be required. Reporting real-life experiences is important to help build evidence for patient management in non-controlled environments. Directacting Direct acting goldstandard gold standard infections recipients realworld real world directacting direct Moreover (DAAs cohort (KT (LT center infection 201 2021 16 analysis 10 5 58.4%, 584 58.4% , 58 4 (58.4%) 57.9% 579 9 (57.9% 896 89 6 89.6 36 conclusion dropout drop out required reallife life noncontrolled non controlled environments 20 202 58.4 (58.4% 57.9 (57.9 8 89. 2 58. (58.4 57. (57. (58. (57 (58 (5 (

SUMMARY OBJECTIVE: The aim of the present study was to evaluate the outcomes of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. METHODS: A retrospective longitudinal observational study was carried out evaluating 38 cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. The outcomes were evaluated in an outpatient follow-up period of 3 months. The assumed significance level was 5%. RESULTS: The indications for transjugular intrahepatic portosystemic shunt were refractory ascites in 21 (55.3%), variceal hemorrhage in 13 (34.2%), and hydrothorax in 4 (10.5%) patients. There was development of hepatic encephalopathy in 10 (35.7%) patients after transjugular intrahepatic portosystemic shunt. From the 21 patients with refractory ascites, resolution was observed in 1 (3.1%) patient, and in 16 (50.0%) patients, there was ascites control. Regarding transjugular intrahepatic portosystemic shunt after variceal bleeding, 10 (76.9%) patients remained without new bleeding or hospitalizations in the follow-up period. The global survival in the follow-up period in patients with and without hepatic encephalopathy was 60 vs. 82%, respectively (p=0.032). CONCLUSION: Transjugular intrahepatic portosystemic shunt can be considered in decompensated cirrhotic patients; however, the development of hepatic encephalopathy which can shorten survival should be focused. OBJECTIVE METHODS followup follow up months 5 5% RESULTS 2 55.3%, 553 55.3% , 55 (55.3%) 34.2%, 342 34.2% 34 (34.2%) 10.5% 105 (10.5% 35.7% 357 35 7 (35.7% 3.1% 31 (3.1% patient 50.0% 500 50 0 (50.0% control 76.9% 769 76 9 (76.9% 6 vs 82 82% p=0.032. p0032 p p=0.032 . 032 (p=0.032) CONCLUSION however focused 55.3 (55.3% 34.2 (34.2% 10.5 (10.5 35.7 (35.7 3.1 (3.1 50.0 (50.0 76.9 (76.9 8 p003 p=0.03 03 (p=0.032 55. (55.3 34. (34.2 10. (10. 35. (35. 3. (3. 50. (50. 76. (76. p00 p=0.0 (p=0.03 (55. (34. (10 (35 (3 (50 (76 p0 p=0. (p=0.0 (55 (34 (1 ( (5 (7 p=0 (p=0. p= (p=0 (p= (p

SUMMARY OBJECTIVE: This study aimed to evaluate the correlation between Nonalcoholic fatty liver disease and cardiac abnormalities. METHODS: Patients with Nonalcoholic fatty liver disease who attended an outpatient clinic in Southern Brazil were prospectively evaluated. Patients should be older than 18 years and have steatosis. RESULTS: A total of 174 patients were evaluated. The mean age was 63±12 years, 65% were women, 71% white, 82.2% hypertensive, 52.3% diabetic, 56.3% obese, and 30% dyslipidemic. There was no association between Nonalcoholic fatty liver disease and cardiac abnormalities, even after adjusting for age, sex, and metabolic syndrome. CONCLUSIONS: The present study did not show a direct correlation between Nonalcoholic fatty liver disease and cardiac abnormalities, regardless of metabolic syndrome.

SUMMARY OBJECTIVE: Nonalcoholic fatty liver disease is the most prevalent cause of chronic liver disease worldwide. Nonalcoholic steatohepatitis is associated with increased mortality rates due to the liver and cardiovascular diseases. The gold standard for discriminating nonalcoholic fatty liver disease activity and staging is the anatomopathological examination, which is an invasive method. In this regard, noninvasive methods, such as scintigraphy, have been under investigation. This study investigated the role of scintigraphy in the diagnosis of nonalcoholic steatohepatitis in obese patients with nonalcoholic fatty liver disease undergoing bariatric surgery. METHODS: Patients undergoing bariatric surgery and liver biopsy were prospectively included. 99mTc-phytate scintigraphy was performed to assess liver/spleen, spleen/heart, and liver/heart uptake ratios, while 99mTc-isonitrile scintigraphy assessed liver/heart ratio. To evaluate the presence of nonalcoholic steatohepatitis, the results of 99mTc-phytate scintigraphy and 99mTc-isonitrile scintigraphy were compared with the anatomopathological examination. RESULTS: Sixty-one patients with nonalcoholic fatty liver disease were allocated into two groups, namely, nonalcoholic steatohepatitis (n=49) and non-nonalcoholic steatohepatitis (n=12). The results of scintigraphic images obtained after the infusion of radiopharmaceutical 99mTc-phytate in liver/spleen, spleen/heart, liver/heart ratios and 99mTc-isonitrile liver/heart ratio presented no difference between groups with and without nonalcoholic steatohepatitis with an accuracy of 47.5, 37.7, 50.8, and 52.5%, respectively. CONCLUSION: Scintigraphy was not proven to be a useful method to differentiate patients with and without nonalcoholic steatohepatitis.

RESUMO CONTEXTO: A doença hepática gordurosa não alcoólica (DHGNA) é considerada, atualmente, um problema de saúde pública global, sendo a mudança no estilo de vida a forma efetiva de tratar a doença. Até o momento não há um padrão de avaliação recomendado para determinar o gasto energético de repouso (GER) de pacientes com DHGNA, para que se possa nortear adequadamente a conduta dietoterápica. OBJETIVO: Avaliar o GER de pacientes com DHGNA através da calorimetria indireta (CI) e comparar com diferentes fórmulas preditivas do GER e com GER através da bioimpedância elétrica (BIA). Avaliar a composição corporal através da BIA, com o estadiamento da DHGNA e com a presença de comorbidades. MÉTODOS: Foram avaliados em pacientes com DHGNA maiores de 18 anos de idade atendidos no ambulatório de Gastroenterologia de um Hospital de nível terciário do Sul do Brasil. O estadiamento da DHGNA foi realizado através de biópsia hepática ou método não invasivo. Peso, altura e índice de massa corporal (IMC) foram determinados em todos os pacientes. Para avaliação da atividade física foi utilizada a versão curta do International Physical Activity Questionnaire. Foram avaliadas as comorbidades hipertensão arterial, diabetes mellitus e dislipidemia. Para a estimativa do gasto energético de repouso utilizou-se as fórmulas de Harris-Benedict, de Jeor Mifflin-St, da Organização Mundial de Saúde e de Schofield. A BIA foi utilizada para avaliação do GER e da massa corporal, e para aferição do GER também se utilizou a CI. Associações entre variáveis categóricas foram testadas com teste χ2 de Pearson e entre grupos com teste de McNemar. O nível de significância assumido foi de 5%. O grau de concordância entre os métodos de mensuração do GER foi aferido pelo teste de Blan-Altman. RESULTADOS: Foram avaliados 67 pacientes, sendo 70,5% do sexo masculino, com média de idade de 59 anos e média de IMC 33,08 kg/m2 ±5,13. O GER médio por CI foi de 1.753 kcal ±614,58. Ao comparar a estimativa do GER por diferentes fórmulas com a calorimetria indireta, apenas a fórmula de Jeor Mifflin-St apresentou diferença estatisticamente significativa (P=0,0001), com uma diferença de +318,49 kcal. A BIA e a fórmula de Harris Benedict apresentaram valores mais próximos à CI, 1.658 e 1.845 kcal respectivamente. CONCLUSÃO: Sugerimos que a fórmula de Jeor Mifflin-St não deva ser utilizada para estimativa do GER em pacientes com DHGNA. Na ausência da CI algumas alternativas podem ser utilizadas com segurança nesta população, como a BIA e as fórmulas preditivas de Harris Benedict, de Schofield e da Organização Mundial de Saúde.

ABSTRACT BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is currently considered a global public health problem, with changes in lifestyle being the effective way to treat the disease. To date, there is no recommended standard of assessment to determine the resting energy expenditure (REE) of patients with NAFLD, so that dietary therapy can be properly guided. OBJECTIVE: To evaluate the REE of patients with NAFLD through indirect calorimetry and compare with different predictive formulas of REE and with REE by electrical bioimpedance analysis (BIA). Assess body composition through BIA, with NAFLD staging and the presence of comorbidities. METHODS: They were evaluated in patients with NAFLD over 18 years of age treated at the Gastroenterology outpatient clinic of a tertiary level hospital in southern Brazil. NAFLD staging was performed using liver biopsy or a non-invasive method. Weight, height and body mass index (BMI) were determined in all patients. The short version of the International Physical Activity Questionnaire was used to assess physical activity. Comorbidities as arterial hypertension, diabetes mellitus and dyslipidemia were evaluated. To estimate energy expenditure at rest, Harris-Benedict, Jeor Mifflin-St, World Health Organization and Schofield formulas were used. BIA was used to assess resting metabolic rate (RMR) and body mass, and to measure RMR, indirect calorimetry was also used. Associations between categorical variables were tested with Pearson’s χ2 test and between groups with McNemar’s test. The level of significance assumed was 5%. The degree of agreement between the REE measurement methods was assessed using the Blan-Altman test. RESULTS: A total of 67 patients were evaluated, 70.5% male, with a mean age of 59 years and a mean BMI of 33.08 kg/m2 ±5.13. The average RMR per CI was 1,753 kcal ±614.58. When comparing the RMR estimate by different formulas with indirect calorimetry, only the Jeor Mifflin-St formula showed a statistically significant difference (P=0.0001), with a difference of +318.49 kcal. BIA and Harris Benedict’s formula presented values closer to CI, 1,658 and 1,845 kcal respectively. CONCLUSION: We suggest that the Jeor Mifflin-St formula should not be used to estimate the RMR in patients with NAFLD. In the absence of indirect calorimetry, some alternatives can be used safely in this population, such as BIA and the predictive formulas of Harris Benedict, Schofield and the World Health Organization.

RESUMO CONTEXTO: A doença hepática gordurosa não-alcoólica (DHGNA) é a doença hepática mais prevalente no mundo. Nos Estados Unidos, a DHGNA já é a segunda causa de transplante hepático. O espectro da doença abrange desde a esteatose simples, que apresenta curso benigno, até esteato-hepatite não-alcoólica (EHNA), que pode progredir para cirrose e suas complicações. O desenvolvimento de métodos não invasivos para o diagnóstico e estadiamento da EHNA e da fibrose hepática visa diminuir a necessidade de biópsia hepática, um procedimento invasivo e não raro associado a complicações. OBJETIVO: Analisar o desempenho do índice triglicerídeo-glicose (TyG Index) para o diagnóstico e estadiamento da DHGNA em pacientes obesos. MÉTODOS: Este é um estudo transversal retrospectivo. Foram analisados todos os prontuários de pacientes candidatos a cirurgia bariátrica em um hospital de referência do Sul do Brasil e calculado o TyG Index, um escore composto por dois exames laboratoriais (triglicerídeos e glicose de jejum), realizados previamente à cirurgia. O desempenho do TyG Index em relação aos achados anatomopatológicos hepáticos foi avaliado, e calculada a curva ROC para avaliação de esteatose simples, EHNA e fibrose hepática. O NAFLD Fibrosis Score (NFS) também foi avaliado. RESULTADOS: Foram avaliados 423 pacientes. O melhor ponto de corte do TyG Index para a exclusão de esteatose simples significativa (grau 2-3) foi de 8,76, com sensibilidade 67,6%, especificidade 65,1%, valor preditivo positivo (VPP) 46,3%, valor preditivo negativo (VPN) 81,8%, acurácia 65,8% e AUROC 0,66 (P=0,005). Na avaliação de EHNA significativa (grau 2-3), o melhor ponto de corte foi de 8,82 com sensibilidade 57,3%, especificidade 58,6%, VPP 33,7%, VPN 78,8%, acurácia 58,8% e AUROC 0,58 (P=0,022). Em relação à fibrose avançada (grau 3-4), o melhor ponto de corte do TyG Index foi de 8,91 com sensibilidade 61,8%, especificidade 62,5%, VPP 13,8%, VPN 94,4%, acurácia 62,4% e AUROC 0,69 (P<0,001). Ao analisarmos o desempenho do NFS no diagnóstico de fibrose avançada, o ponto de corte de <-1,455 excluiu fibrose avançada com sensibilidade 59,4%, especificidade 51%, VPP 11%, VPN 92,4% e acurácia 51,7%. Entretanto, o ponto de corte de 0,676 para fibrose avançada apresentou sensibilidade de 21,9%, especificidade 83%, VPP 11,7%, VPN 91,2% e acurácia 77,3%. A AUROC foi de 0,54 (P=0,480). CONCLUSÃO: O TyG Index não apresentou bom desempenho para o diagnóstico e estadiamento da esteatose simples e da EHNA. Entretanto, foi capaz de excluir fibrose avançada em pacientes obesos candidatos a cirurgia bariátrica.

ABSTRACT BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in the world, and its prevalence is increasing alongside obesity. In United States, NAFLD is already the second leading cause of liver transplantation. The spectrum of the disease ranges from simple steatosis, which has a benign course, to steatohepatitis, which may progress to cirrhosis and its complications. The rising of noninvasive methods for diagnosing and staging non-alcoholic steatohepatitis (NASH) and fibrosis decreases the need of liver biopsy, as well as the costs and the occurrence of complications related to it. OBJECTIVE: To analyze the performance of the triglyceride-glucose index to evaluate steatosis, NASH and liver fibrosis in obese patients with NAFLD. METHODS: This is a retrospective cross-sectional study. Every medical record of patients who were candidates for bariatric surgery at a leading hospital in Southern Brazil were analyzed. The triglyceride-glucose index (TyG Index), a method composed only of two simple laboratory tests (serum triglycerides and fasting glucose levels), was performed prior to surgery. The TyG Index performance regarding the anatomopathological findings was evaluated, and the AUROC curve was calculated to evaluate the best cut-off point for diagnosing steatosis, non-alcoholic steatohepatitis and liver fibrosis grade. Also, the NAFLD fibrosis Score (NFS) was evaluated. RESULTS: A total of 423 patients were evaluated. The TyG Index with a cut-off point of 8.76 excluded significant simple steatosis (grade 2-3) in obese patients, with 67.6% sensitivity, 65.1% specificity, 46.3% positive predictive value (PPV), 81.8% negative predictive value (NPV), 65.8% accuracy and 0.66 AUROC (P=0.005). In the evaluation of NASH, the TyG Index with a cut-off point of 8.82 excluded significant NASH (grade 2-3) with 57.3% sensitivity, 58.6% specificity, 33.7% PPV, 78.8% NPV, 58.2% accuracy and 0.58 AUROC (P=0.022). When evaluating liver fibrosis, the TyG Index with a cut-off point of 8.91 showed a sensitivity of 61.8%, a specificity of 62.5%, a PPV of 13.8 and a NPV of 94.4% for exclusion of advanced fibrosis (F3-4), with a 62.4% accuracy and 0.69 AUROC (P<0.001). When analyzing the performance of NFS in the diagnosis of advanced fibrosis, the cut-off point <-1.455 excluded advanced fibrosis with sensitivity of 59.4%, specificity of 51%, PPV of 11%, NPV of 92.4% and accuracy of 51.7%. However, the cut-off point of 0.676 to diagnose advanced fibrosis presented sensitivity of 21.9%, specificity of 83%, PPV of 11.7%, NPV of 91.2% and 77.3% accuracy. The AUROC was 0.54 (P=0.480). CONCLUSION: TyG Index did not perform well in the diagnosis of significant steatosis and NASH. However, it was able to exclude advanced fibrosis in obese patients who are candidates for bariatric surgery.

ABSTRACT BACKGROUND: Sarcopenia is a common complication in patients with cirrhosis and may lead to increased morbidity and mortality. OBJECTIVE: To investigate the prevalence of sarcopenia and its association with disease severity scores, among patients with cirrhosis. DESIGN AND SETTING: Observational and retrospective cohort study carried out in a tertiary-care hospital in southern Brazil. METHODS: This study was conducted among patients with chronic liver disease who were followed up at the gastroenterology and hepatology outpatient clinic of a tertiary-care hospital in southern Brazil and who underwent computed tomography scans of the abdomen through any indication. RESULTS: We included 83 patients in the study. In the population evaluated, there was a predominance of males (57.80%) and the mean age was 56 years. Hepatitis B or C virus was present in the genesis of the disease in 34.9% of the cases, followed by an etiology of alcohol abuse (30.1%). Sarcopenia was diagnosed in 41 (49.4%) of the patients when the cutoff point for cirrhotic patients was used. There was no significant correlation between the Child-Pugh and MELD severity scores and the occurrence of sarcopenia. CONCLUSION: Sarcopenia presents high prevalence among patients with chronic liver disease, without any association with predictors of severity.

ABSTRACT Background: To analyze the effectiveness and the safety of Sofosbuvir-based regimens to treat patients with chronic hepatitis C virus (HCV) infection and chronic kidney disease (CKD). Methods: A retrospective, observational study in patients with chronic HCV infection and CKD treated with Sofosbuvir-based regimens was performed. Liver fibrosis, comorbidities, HCV genotype and sustained virological resposnse (SVR) at 12th week post-treatment were evaluated. Kidney function was accessed by serum creatinine and glomerular filtration rate (GFR). The assumed level of significance was 5 %. Results: Thirty-five patients were treated. The mean age was 52.1 ± 10.9 years, 19 (54.3 %) were women, 32 (91.4 %) were already kidney transplanted and 3 (8.6 %) were on hemodialysis. The SVR by intention to treat was 88.6 %. The mean GFR was 65.8 ± 28.6 and 63.7 ± 28.3 ml/min pre- and post-treatment respectively (p > 0.05). Treatment was interrupted in 1 (2.85 %) patient due to anemia and in 2 (5.7 %) due to loss of kidney function. Conclusion: Sofosbuvir-based regimens are effective to treat HCV in patients with CKD. In patients with mild CKD this type of therapy seems to be safe.

RESUMO CONTEXTO: A hepatite crônica C (HCC) pode evoluir para cirrose e suas complicações como carcinoma hepatocelular, acarretando morbimortalidade. Conhecer o perfil dos pacientes portadores do vírus da HCC é fundamental para o melhor manejo do tratamento. OBJETIVO: Descrever o perfil dos pacientes portadores de HCC em um programa de saúde pública do sul do Brasil. MÉTODOS: Foi realizado um estudo retrospectivo onde foram incluídos os pacientes com HCC que realizaram o tratamento contra o vírus C em um polo de dispensação e assistência farmacêutica da Secretaria Estadual da Saúde do Estado do Rio Grande do Sul, Brasil. Foram avaliados todos os prontuários dos pacientes tratados entre dezembro/2015 e dezembro/2016. RESULTADOS: Foram avaliados 1.431 registros de pacientes portadores de HCC. O sexo masculino foi o mais prevalente (802; 56%) pacientes. A idade média dos pacientes foi de 58,6±9,9 anos, com variação de 18 a 89 anos. O genótipo 1 foi o mais frequente, em 866 (60,5%) dos pacientes. Noventa (6,3%) pacientes eram transplantados de órgão sólido, sendo que 73 (5,1%) eram transplantados de fígado. A avaliação de fibrose foi realizada em 1.300 (90,8%) pacientes. Dentre estes, 566 (39,6%) foram avaliados através de biópsia hepática. Em relação ao grau de fibrose, 779 (54,4%) apresentavam fibrose grau 4 (cirrose). Os genótipos foram analisados em relação aos diferentes graus de fibrose, sendo observado que o genótipo 3 está associado com o grau 4 de fibrose. O genótipo 1 está associado com alta carga viral. CONCLUSÃO: O presente estudo possibilitou a avaliação do perfil dos pacientes portadores de HCC em um programa de saúde pública do Brasil. Houve uma predominância de HCC no sexo masculino, e a média de idade foi de 59 anos. Apresentam um predomínio do genótipo 1, maior carga viral nos pacientes portadores do genótipo 1 e maior grau de fibrose nos portadores de genótipo 3.

ABSTRACT BACKGROUND: Chronic hepatitis C (CHC) can progress to cirrhosis and its complications as hepatocellular carcinoma, leading to morbidity and mortality. To know the profile of patients with CHC virus is fundamental to optimize management. OBJECTIVE: To describe the profile of patients with CHC in a public health program in Southern Brazil. METHODS: A retrospective study was carried out in patients with CHC who underwent treatment against hepatitis C virus in a dispensation and pharmaceutical assistance center of the Public Health Department of the State of Rio Grande do Sul, South Brazil. All medical records of patients attended between December/2015 and December/2016 were evaluated. RESULTS: A total of 1,431 records of patients with CHC were evaluated. Males were the most prevalent (802; 56%) patients. The mean age was 58.6±9.9 years, ranging from 18 to 89 years. Genotype 1 was the most frequent (866;60.5%) of the patients. Ninety (6.3%) patients were transplanted from a solid organ, and of these, 73 (5.1%) were transplanted from the liver. The fibrosis evaluation was performed in 1,300 (90.8%) patients. Of these, 566 (39.6%) were evaluated through liver biopsy. Regarding the degree of fibrosis, 779 (54.4%) presented fibrosis grade 4 (cirrhosis). The genotype 3 was the most associated with fibrosis grade 4, and genotype 1 was associated with high viral load. CONCLUSION: The present study made possible the evaluation of the characteristics of patients with CHC in a public health program in South Brazil. There was a predominance of CHC in males, and the mean age was 59 years. They presented a predominance of genotype 1, higher viral load in patients with genotype 1 and greater degree of fibrosis in patients with genotype 3.

RESUMO CONTEXTO: A peritonite bacteriana espontânea é uma complicação séria em pacientes cirróticos e as alterações nas características microbiológicas relatadas nos últimos anos podem afetar a escolha do antibiótico utilizado no tratamento. OBJETIVO: Os objetivos do presente estudo são avaliar as mudanças na epidemiologia e perfil de resistência bacteriana dos germes causadores de peritonite bacteriana espontânea em três períodos diferentes ao longo de 17 anos. MÉTODOS: Todos os pacientes cirróticos com peritonite bacteriana espontânea e cultura positiva de fluido ascítico foram estudados retrospectivamente em um hospital de referência no Sul do Brasil. Foram avaliados três diferentes períodos selecionados de forma randômica: 1997-1998, 2002-2003 e 2014-2015. Os organismos infecciosos mais frequentes e a sensibilidade in vitro a antibióticos foram registados. RESULTADOS: No primeiro período (1997-1998) houve 33 casos; os mais comuns foram: E. coli em 13 (36,1%), Staphylococcus coagulase-negativo em 6 (16,7%), K. pneumoniae em 5 (13,9%), S. aureus em 4 (11,1%) e S. faecalis em 3 (8,3%). No segundo período (2002-2003), houve 43 casos, os mais frequentes foram: Staphylococus coagulase-negativo em 16 (35,5%), S. aureus em 8 (17,8%), E. coli em 7 (15,5%) e K. pneumoniae em 3 (6,7%). No terceiro período (2014-2015), houve 58 casos (sete com duas bactérias), os mais frequentes foram: E. coli em 15 (23,1%), S. viridans em 12 (18,5%), K. pneumoniae em 10 (15,4%) e E. faecium 5 (7,7%). Nenhum paciente estava usando profilaxia antibiótica. Quando considerados todos os estafilococos, a prevalência aumentou para taxas da ordem de 50% no segundo período, apresentando redução no terceiro período avaliado. Do mesmo modo, a prevalência de E coli resistente aumentou, chegando a 14%. CONCLUSÃO: Houve modificação da população bacteriana causadora de peritonite bacteriana espontânea, com alta frequência de organismos gram-positivos, bem como aumento da resistência aos antibióticos tradicionalmente recomendados. Este estudo sugere uma provável inclusão iminente de um medicamento contra organismos gram-positivos no tratamento empírico da peritonite bacteriana espontânea.

ABSTRACT BACKGROUND: Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients, and changes in the microbiological characteristics reported in the last years are impacting the choice of antibiotic used for treatment. OBJECTIVE: The aim of the present study is to evaluate the changes in the epidemiology and bacterial resistance of the germs causing spontaneous bacterial peritonitis over three different periods over 17 years. METHODS: All cirrhotic patients with spontaneous bacterial peritonitis and positive culture of ascites fluid were retrospectively studied in a reference Hospital in Southern Brazil. Three periods were ramdomly evaluated: 1997-1998, 2002-2003 and 2014-2015. The most frequent infecting organisms and the sensitivity in vitro to antibiotics were registered. RESULTS: In the first period (1997-1998) there were 33 cases, the most common were: E. coli in 13 (36.11%), Staphylococcus coagulase-negative in 6 (16.66%), K. pneumoniae in 5 (13.88%), S. aureus in 4 (11.11%) and S. faecalis in 3 (8.33%). In the second period (2002-2003), there were 43 cases, the most frequent were: Staphylococus coagulase-negative in 16 (35.55%), S. aureus in 8 (17.77%), E. coli in 7 (15.55%) and K. pneumoniae in 3 (6.66%). In the third period (2014-2015) there were 58 cases (seven with two bacteria), the most frequent were: E. coli in 15 (23.1%), S. viridans in 12 (18.5%), K. pneumoniae in 10 (15.4%) and E. faecium 5 (7.7%). No one was using antibiotic prophylaxis. Considering all staphylococci, the prevalence increased to rates of the order of 50% in the second period, with a reduction in the third period evaluated. Likewise, the prevalence of resistant E. coli increased, reaching 14%. CONCLUSION: There was a modification of the bacterial population causing spontaneous bacterial peritonitis, with high frequency of gram-positive organisms, as well as an increase in the resistance to the traditionally recommended antibiotics. This study suggests a probable imminent inclusion of a drug against gram-positive organisms in the empiric treatment of spontaneous bacterial peritonitis.

Abstract Infection by hepatitis B virus (HBV) is a worldwide public health problem. Chronic HBV infection with high viral replication may lead to cirrhosis and/or hepatocellular carcinoma. Mutant HBV strains, such as the HBV A1762T/G1764A double mutant, have been associated with poor prognosis and higher risk of the patient for developing cirrhosis and/or hepatocellular carcinoma. This study analyzed the presence of the HBV A1762T/G1764A double mutant in patients with chronic HBV and its association with clinical parameters such as viral load, aminotransferases, and HBV antigens. A total of 49 patients with chronic hepatitis B were included in the study, and the HBV A1762T/G1764A double mutant strain was detected in four samples (8.16%) by polymerase chain reaction followed by restriction fragment length analysis (PCR-RFLP). The viral load was not significantly different between patients with or without the double mutant strain (p = 0.43). On the other hand, carriers of the HBV A1762T/G1764A double mutant had higher levels of ALT (p = 0.0028), while AST levels did not differ between groups (p = 0.051). In this study, 75% of the samples with the HBV A1762T/G1764A double mutation were HBeAg negative and anti-HBe positive, reflecting seroconversion even though they still displayed high viral loads. Our study has shown that the HBV A1762T/G1764A double mutant strain circulates in Brazilian patients, and is associated with elevated levels of ALT and HBeAg seroconversion.

RESUMO CONTEXTO A vitamina D é conhecida por possuir propriedades imunomoduladoras, anti-inflamatórias e antifibróticas, relevantes na patogênese e tratamento de muitas causas de doença hepática crônica. OBJETIVO Este estudo tem como objetivo avaliar a associação entre os níveis séricos de vitamina D e os achados histopatológicos em pacientes com infecção crônica do vírus da hepatite C. MÉTODOS Estudo transversal, composto por pacientes com hepatite C crônica. Todos os pacientes foram submetidos à dosagem de vitamina D 25 e análise de dados antropométricos. A biópsia hepática foi realizada em um período máximo de 36 meses antes da inclusão no estudo. RESULTADOS Dos 74 pacientes incluídos no estudo, 45 (60,8%) eram mulheres, média de idade de 57,03±9,24 anos e 63 (85,1%) eram brancos. Não foi observada associação entre os níveis séricos de vitamina D e atividade inflamatória (P=0,699), nem com o grau de fibrose hepática (P=0,269). CONCLUSÃO No presente estudo, não foi observada associação entre a vitamina D e a atividade inflamatória, bem como com o grau de fibrose hepática, em pacientes com hepatite C crônica.

ABSTRACT BACKGROUND Vitamin D is known for its immunomodulatory, anti-inflammatory and antifibrotic properties, which are quite relevant in the pathogenesis and treatment of many causes of chronic liver disease. OBJECTIVE This study aimed to evaluate the association between serum vitamin D levels and the histopathological findings in patients with chronic hepatitis C virus infection. METHODS Cross-sectional study composed of patients with chronic hepatitis C. All patients underwent vitamin D 25 dosage and anthropometric data analysis. Liver biopsy was performed in a maximum 36-month period before inclusion in the study. RESULTS Of the 74 patients included in the study, 45 (60.8%) were women, mean age was 57.03±9.24 years, and 63 (85.1%) were white. No association was observed between the serum levels of vitamin D and inflammatory activity (P=0.699) nor with the degree of liver fibrosis (P=0.269). CONCLUSION In this study, no association was observed between vitamin D and inflammatory activity, as well as the degree of liver fibrosis, in patients with chronic hepatitis C.

ABSTRACT INTRODUCTION: Validation of food frequency questionnaires (FFQs) is recommended for accurate measurement of habitual food consumption. We assessed the relative validity of a FFQ in patients coinfected with hepatitis C virus and human immunodeficiency virus. METHODS: Each patient responded to a FFQ and three 24-hour food recalls. Pearson’s correlation and weighted Kappa index analyses were performed to identify the FFQ relative validity and concordance. RESULTS: De-attenuated correlation coefficients ranged from 0.35 (vitamin B1) to 0.81 (selenium). The concordance index ranged from 0.07 (vitamin C) to 0.51 (calcium). CONCLUSIONS: The FFQ showed satisfactory relative validity for most nutrients.