Introduction

Tenofovir disoproxil fumarate (TDF) when compared to tenofovir alafenamide (TAF) leads to lower body weight and plasma lipid concentrations; the mechanisms of these effects are unknown. (1-3) TDF as opposed to TAF is processed into free tenofovir (TFV) within enterocytes when absorbed from proximal duodenum. (4) The effect of TFV in enterocytes is unknown, but in kidney proximal tubular cells it may cause mitochondrial damage. (5,6) We hypothesize that TDF may damage enterocytes leading to reduced absorption of nutrients from this anatomical site.

Aims & Methods

People living with HIV without known gastrointestinal diseases receiving stable TDF (n=12) or TAF (n=12) containing regimen underwent gastroscopy with biopsies from proximal and distal duodenum. Biopsy samples were scanned with Leica GT450 scanner and measurements taken in Neagen's neaLink digital pathology solution. Serum intestinal fatty acid-binding protein (I-FABP) was measured as a circulating marker of enterocyte damage. Plasma/serum concentrations of nutrients absorbed from proximal duodenum were measured. COX/SDH histochemical staining and electron microscopy (EM) were conducted to evaluate mitochondria.

Results

All participants were male. TDF and TAF groups were matched for third antiretroviral agent (58% integrase strand transfer inhibitor, 42% non-nucleoside reverse transcriptase inhibitor) and age (mean (SD) TDF group 55 (12) and TAF group 57 (16) years). Five patients in TDF group (celiac disease, helicobacter gastritis and 3 cases of esophagitis) and 2 patients in TAF group (2 cases of esophagitis) had a pathological macroscopic or histologic finding (p=0.178). The patient with newly diagnosed celiac disease was excluded from the rest of the analyses. Villi were flatter (337 (59) vs. 397 (42) μm, p=0.016), crypts deeper (200 (46) vs. 176 (27) μm, p=0.243), and villus to crypt ratio lower (1.5 (0.42) vs. 2.5 (0.51), p=0.009) in TDF vs. TAF group. I-FABP concentration was significantly higher in TDF vs. TAF group (3.0 (1.07) vs. 1.8 (0.53) ng/ml, p=0.003). TDF group had numerically but not statistically lower concentrations of folate; vitamins A, B1, D and E. COX/SDH staining showed signs of mitochondrial damage in 10 participants in TDF and 11 in TAF group. EM-studies showed similar mitochondrial damage in both groups.

Conclusion

TDF group displayed signs of villous damage especially in proximal duodenum when compared to TAF group. This together with increased I-FABP suggest enterocyte damage and may contribute to the clinical effect of TDF on lowering body weight and plasma lipid concentrations when compared to TAF. Our data do not support mitochondrial toxicity as the culprit behind the mucosal damage, as COX/SDH histochemistry suggested mitochondrial dysfunction and EM showed similar signs of abnormalities in mitochondrial ultrastructure in both groups. Larger studies are needed to evaluate concentrations of nutrients absorbed from proximal duodenum among TDF users.

References

1.) Kauppinen KJ, et al. Switching from tenofovir alafenamide to tenofovir disoproxil fumarate improves lipid profile and protects from weight gain. AIDS 2022; 36(10):1337-1344.

2.) Mayer KH, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet 2020; 396(10246):239-254.

3.) Sax PE, et al. Tenofovir alafenamide vs. tenofovir disoproxil fumarate in single tablet regimens for initial HIV-1 therapy: a randomized phase 2 study. J Acquir Immune Defic Syndr 2014; 67(1):52-58.

4.) Ruane PJ, et al. Antiviral activity, safety, and pharmacokinetics/pharmacodynamics of tenofovir alafenamide as 10-day monotherapy in HIV-1-positive adults. J Acquir Immune Defic Syndr 2013; 63(4):449-455.

5.) Kohler JJ, et al. Tenofovir renal proximal tubular toxicity is regulated by OAT1 and MRP4 transporters. Lab Invest 2011; 91(6):852-858.

6.) Herlitz LC, et al. Tenofovir nephrotoxicity: acute tubular necrosis with distinctive clinical, pathological, and mitochondrial abnormalities. Kidney Int 2010; 78(11):1171-1177.

Introduction

Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) is the most prevalent hepatic disorder worldwide. While histology remains the gold standard, a shift is evident in emerging studies favoring Magnetic Resonance Imaging Proton Density Fat Fraction (MRI-PDFF) over biopsy as a reliable alternative for steatosis assessment. Similarly, Controlled Attenuation Parameter (CAP) enables the noninvasive assessment of liver steatosis.

Aims & Methods

To assess the accuracy of CAP for MASLD diagnosis as defined by MRI-PDFF. We performed a cross-sectional, diagnostic accuracy study with prospectively collected data. We included consecutive adult participants with type 2 diabetes (T2D) and increased body mass index (BMI ≥25 kg/m²). We used receiver operating characteristic (ROC) curve analyses to assess the accuracy of CAP for diagnosing MASLD (MRI-PDFF ≥5%), and hepatic fat content (HFC) ≥10%. For each ROC analysis, we calculated the area under the ROC (AUROC) alongside 95% Confidence Intervals (CIs), and cutoffs for ruling out (sensitivity >90%) and ruling in (specificity >90%) the target condition. For each cutoff, we calculated the negative (NPV) and positive predictive values (PPV), as well as negative (LRn) and positive (LRp) likelihood ratios with their 95% CIs.

Results

We included 113 participants (58.4% males, mean age 59.6 years). Most participants (95.6%) had a BMI ≥30 kg/m². CAP measurements were performed with the M probe in 36.3% of the participants, and the remaining (63.7%) were scanned with the XL probe. MRI-PDFF values ranged from 1.9% to 37.8% covering the whole spectrum of steatosis. The prevalence of MASLD was 72.6%. The AUROC of CAP for MASLD diagnosis was 0.82 (0.74 to 0.89). The threshold for ruling out MASLD was 249 dB/m yielding a sensitivity (Sens) of 90.2% (81.7 to 95.7), specificity (Sp) 35.5% (19.2 to 54.6), LRp 1.40 (1.07 to 1.83), LRn 0.27 (0.12 to 0.62), PPV 78.7% (73.8 to 82.9) and NPV 57.9% (37.9 to 75.6). Similarly, the threshold for ruling in MASLD was 328 dB/m yielding a Sens, Sp, LRp, LRn, PPV and NPV of 47.6% (36.4 to 58.9), 90.3% (74.2 to 98.0), 4.91 (1.64 to 14.75) and 0.58 (0.46 to 0.74), 92.9% (81.2 to 97.5) and 39.4% (34.0 to 45.2), respectively. The AUROC of CAP for detecting HFC ≥10% was 0.81 (0.73 to 0.88). CAP thresholds for ruling out/in HFC ≥10% were 271 dB/m and 345 dB/m respectively. CAP measurements with IQR < 30 dB/ did not improve the accuracy of CAP for MASLD diagnosis

Conclusion

CAP has acceptable diagnostic accuracy in identifying patients with MRI-PDFF defined MASLD. Thresholds below 249 and 271 dB/m can be used to exclude MALSD and HFC ≥10% with adequate sensitivity. Similarly, CAP values over 328 and 345 dB/m can rule in MASLD and HFC ≥10% respectively.

Disclosure

This study was supported by the Hellenic Association for the Study and Education of Diabetes Mellitus

Introduction

Increased intestinal permeability, or leaky gut, is a condition where the gut's epithelial barrier is compromised, allowing bacteria and toxins to enter the blood stream. In liver cirrhosis, this can exacerbate liver damage and accelerate disease progression by perpetuating inflammation and immune system activation. Accurate assessment of this dysfunction is critical to the management of cirrhotic patients, but traditional methods such as serum markers and indirect assays often lack specificity and sensitivity.
Confocal laser endomicroscopy (CLE) is an advanced imaging technique that provides real-time, high-resolution visualisation of the gastrointestinal tract at the cellular and subcellular levels. CLE is used to diagnose leaky gut by directly observing disruptions in the intestinal mucosa. It integrates a confocal microscope within an endoscope, enabling in vivo histology-like imaging during routine endoscopic examinations.

Aims & Methods

We aimed to use confocal laser microendoscopy (CLE) in the diagnosis of intestinal barrier dysfunction by direct observation of the intestinal mucosa, in patients with liver cirrhosis. CLE (Cellvizio, Mauna Kea Technologies) was performed in the second part of the duodenum following intravenous administration of 2.5 – 5 mg of fluorescein in 58 patients with liver cirrhosis of various aetiologies. These patients were undergoing routine endoscopic surveillance or therapeutic intervention for oesophageal varices. The study cohort consisted of 39 men (61.9%) and 19 women (30.2%), with a mean age of 53.9 ± 14.0 years. We collected and analysed the most recent results of hepatic venous pressure gradient (HVPG), liver stiffness measurement (LSM), and fibrosis index for liver fibrosis (Fib-4). A Watson score of 1 indicates normal barrier function, while a Watson score of 2 indicates impaired barrier function. Data are given as mean± standard deviation, statistical analysis included Chi-square tests and Student’s t-tests, with a significance level set at p<0.05. NS=not significant.

Results

We observed a gradation of intestinal barrier dysfunction that correlated with the severity of liver cirrhosis. Specifically, of the 35 patients with Child-Pugh A cirrhosis, 18 (51.4%) had a Watson score of 2. In the group of 14 patients with Child-Pugh B cirrhosis, 9 (64.3%) had a Watson score of 2 and of the 9 patients with Child-Pugh C cirrhosis, 8 (88.9%) had a Watson score of 2, further underscoring the trend of increasing intestinal barrier dysfunction with increasing liver disease severity (p<0.05). In contrast, no significant differences in hepatic venous pressure gradient (HVPG) were observed between patients with Watson score 1 (16.8 ± 6.2 mmHg) and Watson score 2 (17.2 ± 6.2 mmHg, p NS). Similarly, liver stiffness measurements (LSM) showed no statistical difference between patients with Watson score 1 (39.0+/-23.7 kPa) and those with score 2 (40.2 ± 22.9 kPa) (p NS)=. Similarly, Fib-4 was 4.5 +/-3.1 in patients with Watson score 1 and 5.7+/-3.6 in patients with Watson 2 (p NS).

Conclusion

The findings suggest an association between the severity of liver cirrhosis and impaired intestinal barrier function as assessed by CLE. This impairment does not correlate with changes in haemodynamic parameters or liver fibrosis. The CLE promises to provide accurate and immediate diagnostic data and to improve our understanding of the pathophysiological changes in the gut associated with liver cirrhosis. Further research is needed to explore the mechanisms linking the severity of cirrhosis to intestinal barrier dysfunction and its clinical implications.

Disclosure

No conflict of interest to declare

Introduction

Steatotic liver disease (SLD) encompasses a spectrum of conditions, including metabolic dysfunction-associated SLD (MASLD), alcohol-related liver disease (ALD), and the overlapping category of MetALD. SLD affects more than a third of adults globally, but the majority remain undiagnosed, partially due to its lack of symptoms and limited awareness among patients and physicians. Adults undergoing screening colonoscopy, typically aged ≥50 years, represent a key population for targeted SLD detection, as they have a higher prevalence of cardiometabolic risk factors and is already engaged with preventive healthcare.

Aims & Methods

We examined 610 consecutive individuals aged ≥50 years with no known history of chronic liver disease who were referred for a colonoscopy for colorectal cancer screening. The protocol included sonographic assessment of liver steatosis and point shear wave elastography (pSWE) for liver fibrosis quantification, anthropometric measurements, biochemistry, medical history and alcohol intake evaluation. From the collected data, non-invasive fibrosis scores were calculated and used for aetiological and risk stratification.

Results

A total of 543 patients were included in the final analysis, after excluding patients with an invalid pSWE measurement (5.3%, n=29) and then excluding patients with incomplete results (n=38). The median age was 64 years (IQR 57-70) and 54.0% were male. The median BMI was 28.7 kg/m² (IQR 25.8–31.4) in males and 28.3 kg/m² (IQR 24.2-31.5) in females. SLD was identified in 63.4 % (n=344) of participants. Elevated liver stiffness (pSWE ≥ 1.30 m/s) was found in 26.9 % (n=146), and 4.8% (n=26) had values ≥1.70 m/s, suggestive of compensated advanced chronic liver disease. Among patients with pSWE ≥ 1.30 m/s, MASLD was the predominant aetiology (69.9%, n=102), followed by MetALD (15.8%, n=23), ALD (1.4%, n=2), cryptogenic (11.6%, n=17) and other etiologies (1.4%, n=2). Preselection using EASL-EASD-EASO criteria (i.e. presence of type 2 diabetes or central obesity plus ≥1 cardiometabolic risk factor and elevated liver enzymes) would have detected 365 at-risk individuals (67.2% of the cohort) of whom 55.9% (n=204) had a FIB-4 index ≥1.30. This approach would have identified only 30.4% (n=38) of all the patients with MASLD/MetALD with elevated liver stiffness (n=125).

Conclusion

Opportunistic screening for SLD in patients undergoing screening colonoscopy could be a useful strategy for detecting asymptomatic and potentially progressive liver disease. This approach identified a high prevalence of SLD (63.4%) and elevated liver stiffness (26.9%) in this population, primarily due to MASLD and MetALD. The integration of ultrasound and elastography added minimal burden to the existing workflow while enabling early risk stratification without the need for additional patient visits or referrals.

References

1 Tacke F, Horn P, Wong VWS, Ratziu V, Bugianesi E, Francque S, et al. EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). Journal of Hepatology [Internet]. 2024 Jun 7;81(3):492–542.
2 Lazarus JV, Miralles-Sanchez JE, Agirre-Garrido L, Brachowicz N, Nicolàs A, Armenta A, et al. A call to action to address the steatotic liver disease public health threat in Barcelona. The Lancet Regional Health - Europe [Internet]. 2025 Mar 22;52:101272.
3 Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement. Radiology [Internet]. 2020 Jun 9;296(2):263–74.

Introduction

ESSENCE (NCT04822181) is an ongoing 247-week Phase 3, randomised, placebo-controlled trial evaluating the effect of the glucagon-like peptide-1 analogue, semaglutide 2.4 mg subcutaneous once weekly (OW) in participants with non-cirrhotic metabolic dysfunction-associated steatohepatitis (MASH). We report the baseline characteristics of the randomised participants.

Aims & Methods

Following a 14-week screening phase, 800 participants (part 1) of 1200 planned (part 2) with MASH and fibrosis stages 2/3 (F2/F3) were randomised 2:1 to receive semaglutide 2.4 mg subcutaneous OW or placebo OW added to standard of care. In part 1, the two primary endpoints at 72 weeks are resolution of steatohepatitis and no worsening of liver fibrosis, and improvement in liver fibrosis and no worsening of steatohepatitis. Based on a central pathologist evaluation, inclusion criteria were histological presence of steatohepatitis stages F2/F3 per the Nonalcoholic Steatohepatitis Clinical Research Network classification, and a non-alcoholic fatty liver disease activity score (NAS) of ≥ 4, with a score of ≥ 1 in steatosis, lobular inflammation and hepatocyte ballooning.

Results

800 participants (250 F2; 550 F3) were randomised. Mean (SD) age was 56 (11.6) years; 57.1% were female; ≥ 99% had ≥ 1 cardiometabolic risk factor(s) in accordance with the metabolic dysfunction-associated steatotic liver disease (MASLD) definition. Mean (SD) NAS was 5.05 (0.95), and higher in F3 versus F2 (5.11 [0.95] vs 4.92 [0.93], respectively). Notably, participants with a higher NAS had more cardiometabolic risk factors for MASLD (52.9% with NAS ≥ 5 vs 45.3% with NAS 4). Similarly, a greater proportion of participants with F3 had all five cardiometabolic risk factors versus F2 (52.9% vs 44.8%, respectively). Although cardiometabolic comorbidities were highly prevalent, 44.5% of participants did not have type 2 diabetes (T2D), and 27.3% did not have obesity. Normal liver transaminases were observed in 26.3% of participants (28% F2; 26% F3). Mean (SD) FibroScan liver stiffness was 12.8 (6.9) kPa, and values of < 8 kPa were observed in 15.3% of participants. Mean (SD) controlled attenuation parameter value was 329 (46) dB/m; mean (SD) enhanced liver fibrosis (ELF) score was 10.0 (1.0), and 43.5% of participants had an ELF score of < 9.8. Overall, 8.8% and 9.0% of participants with/without T2D did not meet any of the following non-invasive criteria: Fibrosis-4 index ≥ 1.3, vibration-controlled transient elastography ≥ 8.1, or ELF ≥ 9.8, and more participants with F2 (14.7–16.4%) did not meet these criteria versus F3 (4.5–6.7%).

Conclusion

The ESSENCE baseline population includes participants with significant fibrosis (F2 and F3) and approximately 91% of the trial population had ≥ 1 positive diagnostic non-invasive test. Cardiometabolic risk factors were found in ≥ 99% of participants, and in increased numbers in those with higher NAS and fibrosis stages.
This is an encore of an abstract that will be presented for the first time at the European Association for the Study of the Liver (EASL) Congress, 5–8 June 2024, Milan, Italy.

Disclosure

The ESSENCE trial is funded by Novo Nordisk A/S.
PNN: reports grants from Novo Nordisk, and has received consulting fees from Novo Nordisk, Boehringer Ingelheim, Gilead, Intercept, Poxel Pharmaceuticals, Bristol Myers Squibb (BMS), Pfizer, Sun Pharma, Madrigal and GSK. PNN also reports honoraria as a speaker for Novo Nordisk and AiCME; support for attending meetings for Novo Nordisk; and participation on an advisory board for Novo Nordisk, Boehringer Ingelheim, Gilead, Intercept, Poxel Pharmaceuticals, BMS, Pfizer, Sun Pharma, Madrigal and GSK.
EB: served as a consultant or advisory board member for Boehringer Ingelheim, Gilead, Intercept, Merck, Novo Nordisk, Pfizer, ProSciento, and as a speaker for Gilead, Intercept, Merck, Novo Nordisk and Pfizer. EB has also received a research grant from Gilead for fatty liver research.
VR: received consulting fees from Novo Nordisk, Sagimet, Madrigal, Enyo, Poxel, Northsea, Intercept and ProSciento, and research grants (to institution) from Gilead and Intercept.
MER: consults for Boehringer Ingelheim, CytoDyn, GSK, Novo Nordisk, HistoIndex, Intercept, Madrigal, NGM Bio and Sonic Incytes.
MR: reports grants from Boehringer Ingelheim and Novo Nordisk, and has received fees for consulting or participation in advisory boards for Boehringer Ingelheim, Echosens, Eli Lilly and Novo Nordisk. MR also reports honoraria as a speaker for AstraZeneca, Boehringer Ingelheim, Novo Nordisk and Madrigal.
AJS: consults for and advises Avant Santé and AstraZeneca. AJS also consults for and has received grants from Akero, BMS, Intercept, Eli Lilly, Madrigal and Novo Nordisk. AJS consults for and owns stock in Rivus, and also consults for AGED Diagnostics, Albireo, Alnylam, Altimmune, Boehringer Ingelheim, 89Bio, Echosens, Genentech, Gilead, GSK, HistoIndex, Mallinckrodt, Merck, NGM Bio, Novartis, PathAI, Pfizer, Poxel, Regeneron, Salix, Siemens, Surrozen, Takeda, Terns and Zydus. AJS owns stock in Durect, Exalenz, Genfit, Indalo, Inversago and Tiziana, and has received royalties from Elsevier and Wolters Kluwer.
KAE, IK, LHØ, DV and JZ: employees and stockholders of Novo Nordisk A/S.

Introduction

There is a paucity of information on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMT) in Japan where ER for early gastric cancer is extremely popular.

Aims & Methods

A multicenter retrospective study was conducted to elucidate the current situation of ER for gastric SMT in Japanese endoscopic practice. Clinicopathological data of consecutive patients with gastric SMT who underwent ER in 12 Japanese hospitals were collected from the first case until August 2020.

Results

A total of 117 patients with 118 lesions were enrolled. The number of patients with gastric SMT who underwent ER increased over the years. The mean (SD) endoscopic tumor size was 20 (7.2) mm. The growth type was primarily intraluminal (90%). 87 (74%) of the procedures were performed in an operating room under general anesthesia. The tunneling method was used in 5 (4%) cases. The mean (SD) resection and wound closure times were 58 (38) min and 31 (41) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full-thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for pneumoperitoneum. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Two cases of delayed bleeding were managed by endoscopic hemostasis, one of which required a blood transfusion. Gastrointestinal stromal tumors were the most common pathology (74%). The R0 resection rate was 76%. Survival and recurrence on August 31, 2021, were confirmed in 112 patients (96%) with a mean (SD) follow-up period of 4.3 (2.9) years. 109 (94%) were confirmed alive, the vital status of five patients was unknown, and three patients had died of other diseases. No recurrence was observed. The 5-year overall survival rate was 98.9% (95% confidence interval, 97.8−100%).

Conclusion

The performance of ER for gastric SMT is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study.

Introduction

Endoscopic submucosal dissection (ESD) is a common treatment for early-stage gastrointestinal cancers, but managing delayed bleeding from post-ESD ulcers can be challenging. With more patients taking antithrombotic drugs, reliable bleeding prevention methods are crucial. This study presents the Dumpling technique, a new solution for preventing delayed bleeding from these ulcers.

Aims & Methods

Dumpling technique: The technique involves using a double-lumen catheter to inject fibrin glue into the pocket created after suturing an artificial ulcer post-ESD. This technique not only covers the ulcer but also provides a tamponade effect through compression. The fibrin glue is encased by the sutured mucosa, giving it the appearance of a dumpling. An important point of this technique is the use of a double-lumen catheter for fibrin glue injection. Fibrin glue consists of a fibrinogen solution and thrombin solution. Single-lumen catheters cannot be used because the two solutions begin to form a gel in just a few seconds when mixed. One advantage of this technique is that it combines existing products, so no new product development time is required.
An artificial ulcer was created in the resected bovine rectum by ESD flow, fixed to a jig, and a defect of 2.7 mm in diameter was created using an Aorta/Vein Punch. Pig blood that had lost coagulability was then injected to create a hemorrhage model. First, pressure resistance was measured after clip sutures only. Next, the same ulcer was used as is, the blood was washed out, fibrin glue was injected, and pressure resistance was measured again and compared between the two groups (Clip suture group vs Dumpling technique group). In addition, to confirm the feasibility of the technique, the Dumpling technique was performed endoscopically on porcine explanted stomach and bovine explanted rectum, and the excised specimens were evaluated.

Results

The mean ± SD pressure resistance in the bleeding model was 40.2 ± 14.0 mmHg in the clip suture group and 134.5 ± 36.8 mmHg in the Dumpling technique group (N = 5). Feasibility checks confirmed that suture spacing could be performed endoscopically without problems by setting the suture spacing to allow catheter tip insertion. The resection specimen was confirmed to be sufficiently filled with fibrin glue in the pocket.

Conclusion

This study suggests that the Dumpling technique improves the bleeding prevention effect of ulcer closure. Although various methods of ulcer suturing are still being developed, the injection of fibrin glue itself is expected to be adoptable by many clinicians because it does not require high skill if the tip of the catheter can be inserted through the gap between the sutures. We plan to confirm the feasibility of the Dumpling method in an in vivo study using pigs, followed by a clinical trial to confirm the effectiveness of the Dumpling technique.

Disclosure

Mr. Takegawa is employees of KM Biologics Co., Ltd. and the fibrin glue (BOLHEAL®) used in this article is manufactured by KM Biologics Co., Ltd.