dr. javier ampuero - gehep2018 · hipertransaminasemia alt / ast > 40 ui/l excluir causas...
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Dr. Javier Ampuero
UGC Enfermedades Digestivas
Hospital Universitario Virgen del Rocío
Sevilla, España
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Esto es cosa de
mayores
Estoy
perfectamente, no
tengo síntomas ¿Cómo voy a tener
hígado graso?
¡Pues anda que yo!
¿Hígado graso? Anda
que no hay cosas más
importantes!
El hígado graso
siempre ha existido y
nunca ha sido
importante
Si no se contagia y
no duele para tanto
no será
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Varón de 66 años.
No hábitos tóxicos.
Obesidad grado I (IMC 32).
Dislipemia, en tratamiento con simvastatina 20 mg/24h.
Esófago de Barret, en seguimiento.
Colelitiasis sintomática.
Colecistectomía.
Ampuero et al, Aliment Pharmacol Ther 2018
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Estes et al, J Hepatol 2018
48% 118%88%
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Mahady et al, J Gastroenterol Hepatol 2018
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Wong et al, Aliment Pharmacol Ther 2017
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Ampuero et al, Aliment Pharmacol Ther 2018 Golabi et al, Medicine 2018
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Verna et al, Lancet Gastroenterol Hepatol 2017
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Vodkin et al, Aliment Pharmacol Ther 2015 Lake et al, Curr HIV/AIDS Rep 2017
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Mittal et al, Clin Gastroenterol Hepatol 2016Kabbany et al. Am J Gastroenterol 2016
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Goldberg et al, Gastroenterology 2017Younossi et al, Clin Gastroenterol Hepatol 2018
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Brea et al, Arterioscler Thromb Vasc Biol 2005 Targher et al, Diabetes Care 2006
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Soderberg et al
Adams et al
Dam-Larsen et al
Rafiq et al
Histology
Histology
Histology
Histology
24 years
8 years
20 years
19 years
1
1
2
1
2010
2005
2004
2009
Angulo et al Histology 9 years 12013
Stepanova et al Histology 12 years 12013
Ong et al Imaging 9 years 12008
(25%)
(38%)
(13%)
(38%)
(28%)
(35%)
(25%)
Ekstedt et al Histology 26 years 12015 (43%)
Ekstedt et al, Hepatology 2015 Vilar-Gomez et al, Gastroenterology 2018
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Adams et al, Gut 2017
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Kim et al, J Hepatol 2018
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22,520,3
8,1 8,5 10 9,9
17,8
4,3
19,7
15,311,8 12,3
16,1
10,3
17,4
7,65,2
1,8 2,3 4 3,77
0,8
10,5
3,7 3,50,8
3,1 2,4 4,1
0
5
10
15
20
25
30
35
40
NAFLD No NAFLD
Targher et al, Diabet Metab 2016 Sung et al, J Clin Endocrinol Metab 2013
Incidencia de DM (%)
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Ampuero et al, AASLD 2018
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Dulai et al, Hepatology 2017 Yonoussi et al, Hepatol Commun 2017
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¿Cómo abordar el
diagnóstico de la EHGNA?
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Almpanis et al, Ann Gastroenterol 2016
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Steatosis
• Séricos•Hepatic Steatosis Index
•Fatty Liver Index
• Imagen•Ultrasound
•CAP
•PDFF
•MRS
NASH
• Séricos•OWLiver
• Imagen•DeMILI (NASH-MRI)
Fibrosis
• Séricos•NAFLD Fibrosis Score
•FIB-4
•Hepamet Fibrosis Score
• Imagen•Transient elastography
•ARFI
•DeMILI (Fibro-MRI)
•MRe
LIVER BIOPSY
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Steatosis
• Séricos•Hepatic Steatosis Index
•Fatty Liver Index
• Imagen•Ultrasound
•CAP
•PDFF
•MRS
NASH
• Séricos•OWLiver
• Imagen•DeMILI (NASH-MRI)
Fibrosis
• Séricos•NAFLD Fibrosis Score
•FIB-4
•Hepamet Fibrosis Score
• Imagen•Transient elastography
•ARFI
•DeMILI (Fibro-MRI)
•MRe
LIVER BIOPSY
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Hepatic Steatosis Index (HSI)
Fórmula: 8 * (ALT/AST) ratio + BMI + 2 (if DM) + 2 (if female)
Interpretación: HSI<30: No NAFLD; HSI>36 NAFLD
Fatty Liver Index (FLI)
Fórmula:
100 / (1+EXP((-1)*(0.953*Ln(Tg))+(0.139*BMI)+(0.718*Ln(GGT))+(0.053*(WC))-15.475))
Interpretación: FLI<30: No NAFLD; FLI>60 NAFLD
HEPATIC STEATOSIS INDEX
AST U/L
ALT U/L
SEXO FEMENINO SI/NO
DIABETES TIPO 2 SI/NO
PESO kg
TALLA m
IMC (kg/m2) Kg/m2
HSI
FATTY LIVER INDEX
Triglicéridos mg/dl
GGT U/L
Perímetro abdominal cm
PESO kg
TALLA m
IMC (kg/m2) Kg/m2
FLI
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Ultrasonography
Sensitivity 60-94%, Specificity 84-95%
Do not detect mild fat infiltration < 30%!!!!
Controlled Attenuation Parameter (CAP)
CAP is a measure of the ultrasound attenuation which corresponds to the decrease in amplitude of
ultrasound waves as they propagate through the liver.
Proton Density Fat Fraction (MRI-PDFF)
Romero-Gómez et al, J Hepatol 2017Harrison et al, EASL 2017
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Steatosis
• Séricos•Hepatic Steatosis Index
•Fatty Liver Index
• Imagen•Ultrasound
•CAP
•PDFF
•MRS
NASH
• Séricos•OWLiver
• Imagen•DeMILI (NASH-MRI)
Fibrosis
• Séricos•NAFLD Fibrosis Score
•FIB-4
•Hepamet Fibrosis Score
• Imagen•Transient elastography
•ARFI
•DeMILI (Fibro-MRI)
•MRe
LIVER BIOPSY
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OWLiver
DeMILI
NASH
Gallego-Durán et al, Sci Rep 2016Mayo et al, Hepatology Communications 2017
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Steatosis
• Séricos•Hepatic Steatosis Index
•Fatty Liver Index
• Imagen•Ultrasound
•CAP
•PDFF
•MRS
NASH
• Séricos•OWLiver
• Imagen•DeMILI (NASH-MRI)
Fibrosis
• Séricos•NAFLD Fibrosis Score
•FIB-4
•Hepamet Fibrosis Score
• Imagen•Transient elastography
•ARFI
•DeMILI (Fibro-MRI)
•MRe
LIVER BIOPSY
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NAFLD Fibrosis ScoreFórmula: 1.675 + 0.037 x age + 0.094 x BMI + 1.13 x IFG/T2DM + 0.99
x AST/ALT ratio – 0.013 x platelets – 0.66 x albumin
Interpretación: NFS<-1.455: Fibrosis leve (F0-F1); NFS>0.675: Fibrosis
avanzada (F3-F4).
FIB-4Fórmula: (Age x AST ) / (Platelets x √ALT)
Interpretación: FIB-4 <1.30: Fibrosis leve (F0-F1); FIB-4>2.67: Fibrosis
avanzada (F3-F4).
Hepamet Fibrosis ScoreFórmula: Incluye Edad, Sexo, DM, HOMA, AST, Albúmina y
Plaquetas.
Interpretación: HFS <0.12: Fibrosis leve (F0-F1); HFS >0.47: Fibrosis
avanzada (F3-F4).
Ampuero et al, EASL 2018 (manuscrito en revision)Angulo et al, Hepatology 2007
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Ampuero et al, EASL 2018 (manuscrito en revisión)
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Transient Elastography
Wong et al, Hepatology 2010
MR Elastography
Dulai et al, J Hepatol 2016
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Propuesta de manejo diagnóstico no
invasivo de sospecha de EHGNA
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Reevaluación anual
Evidencia de EsteatosisEcografía abdominal
Derivación a
Especialista
¿Presencia fibrosis?
Riesgo Alto Riesgo Bajo
DeMILI
Liver MultiScan
BiopsiaFibroscan
ARFI
Mantiene factores de riesgo
Factores de RiesgoObesidad
Diabetes mellitus
Otros factores metabólicos
HipertransaminasemiaALT / AST > 40 UI/L
Excluir causas secundarias
Excluir consumo alcohol
Ampuero J, Opinión personal
Hepamet Fibrosis ScoreFIB-4
NAFLD Fibrosis Score
Riesgo Intermedio