编辑：肝脂肪变性对慢性乙型肝炎患者肝硬化的影响

StephenW

Editorial: effect of hepatic steatosis on liver stiffness in patients with chronic hepatitis B

Although liver stiffness measurement (LSM) using transient elastography (TE) is generally accepted as a reliable method to quantify fibrotic burden in patients with chronic liver diseases, its accuracy has been challenged because of several confounders, such as high alanine aminotransferase (ALT Level, which may lead to overestimation.1,2 Hepatic steatosis is common both in the general population as well as patients with chronic viral hepatitis. 2‐ 4 The prevalence of non-alcoholic fatty liver disease (NAFLD) in Patients with chronic hepatitis B (CHB) ranges from 18% to 40%. 5,6 Thus, LSM may be influenced by the extent of hepatic steatosis, because the shear wave must propagate through the fatty liver parenchyma. Of hepatic steatosis on LSM remains controversial.7, 8In the study by Shen et al,9 the median LSM was 7.4 kPa (interquartile range [IQR]: 6.6‐8.8 kPa) for S2‐S3, which Was significantly higher than the values ​​of 5.9 kPa (IQR: 4.7‐8.0 kPa) for S0 status and 6.3 kPa (IQR 5.3‐8.2 kPa) for S1 status (P = 0.005) among CHB patients with no significant fibrosis (F0‐ F1 status). On the other hand, no significant LSM difference was evident among F2‐F4 CHB patients according to the extent of hepatic steatosis (P = 0.7). These data are clinically relevant because the prevalence of NAFLD among real‐world Patients with CHB is high, and concomitant metabolic phenotypes (including NAFLD) are significantly associated with a higher risk of disease progression.3,10However, several critical points should be borne in mind when in‐terpreting the results.9Firstly, the rates Of S2‐S3 diagnosis based on histological findings versus controlled attenuation parameter (CAP)‐based assessments differed (n = 48 and n = 127, respectively); this may indicate that the diagnostic performance of TE for hepatic steatosis is sub
optimal. In addition, TE may inaccurately identify patients without significant fibrosis who would benefit from assessment of hepatic steatosis according to this study; it is well‐known that the diagnostic performance of TE for early stage fibrosis is suboptimal. Secondly, the potential effects of higher ALT levels (median = 56.5 and 50.0 U/L in patients with and without hepatic steatosis, respectively) were inadequately analysed. similar, the potential effects of histological necroinflammatory activity on LSM require further attention. It remains unclear whether LSM Overestimation is attributable primarily to hepatic steatosis or concomitant necroinflammation, assessed either biochemically or histologically. Third,  as  in previous studies,  the proportions of patients of various steatosis grades were skewed, which  may have led to statistical bias.  In addition,  little is known about  the  effect of coexisting fat burden on patients  with  chronic viral  hepatitis.  Thus,  the  results  should  be  validated  in  other  study  populations,  with  different  steatosis  grades  and  the  aetiologies  of  underlying liver diseases.In  conclusion,  future  large,  well‐designed  studies  are  required  to  validate  these  results,  and  to  develop  a  simple  diagnostic  algorithm allowing for accurate interpretation of the fibrotic burden, as revealed by LSM, without any risk of overestimation (especially for patients with CHB but without significant fibrosis)

StephenW

编辑：肝脂肪变性对慢性乙型肝炎患者肝硬化的影响

尽管使用瞬时弹性成像（TE）的肝硬度测量（LSM）通常被认为是量化慢性肝病患者纤维化负荷的可靠方法，但其准确性受到一些混杂因素的挑战，例如高丙氨酸氨基转移酶（ALT水平，这可能导致高估.1,2肝脏脂肪变性在一般人群和慢性病毒性肝炎患者中都很常见.2-4慢性乙型肝炎患者（CHB）非酒精性脂肪性肝病（NAFLD）的患病率因此，LSM可能受肝脏脂肪变性程度的影响，因为剪切波必须通过脂肪肝实质传播。对LSM的肝脂肪变性仍有争议.7,8研究中，LSM可能受肝脏脂肪变性程度的影响。通过Shen等[9]，S2-S3的中位LSM为7.4 kPa（四分位距[IQR]：6.6-8.8 kPa），显着高于5.9 kPa（IQR：4.7-8.0 kPa）的值。 S0状态和6.3 k对于没有显着纤维化（F0-F1状态）的CHB患者，S1状态（P = 0.005）的Pa（IQR 5.3-8.2kPa）。另一方面，根据肝脏脂肪变性程度，F2-F4 CHB患者之间没有明显的LSM差异（P = 0.7）。这些数据具有临床相关性，因为现实世界CHB患者中NAFLD的患病率很高，伴随的代谢表型（包括NAFLD）与疾病进展的高风险显着相关[3,10]。但是，应该承担几个关键点。首先，基于组织学发现与基于受控衰减参数（CAP）的评估的S2-S3诊断率不同（分别为n = 48和n = 127）;这可能表明TE对肝脏脂肪变性的诊断性能较低
最佳。此外，根据这项研究，TE可能不准确地识别没有显着纤维化的患者，这些患者将从肝脂肪变性评估中受益;众所周知，TE对早期纤维化的诊断性能不是最理想的。其次，没有充分分析ALT水平较高的潜在影响（分别在有或没有肝脂肪变性的患者中位数= 56.5和50.0 U / L）。类似地，组织学坏死性炎症活动对LSM的潜在影响需要进一步关注。尚不清楚LSM高估是否主要归因于肝脏脂肪变性或伴随的坏死性炎症，无论是生物化学还是组织学评估。第三，与先前的研究一样，各种脂肪变性等级的患者比例均有偏差，这可能导致统计学偏差。 此外，对于慢性病毒性肝炎患者共存脂肪负荷的影响知之甚少。 因此，结果应该在其他研究人群中得到验证，具有不同的脂肪变性等级和潜在的肝脏疾病的病因。总之，未来大型，精心设计的研究需要验证这些结果，并开发一种简单的诊断算法，允许 LSM揭示的纤维化负荷的准确解释，没有任何高估的风险（特别是对于CHB但没有明显纤维化的患者）

StephenW

https://onlinelibrary.wiley.com/doi/pdf/10.1111/apt.15364