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Institute of Liver & Biliary Sciences

APASL STC CAIRO 2014. Institute of Liver & Biliary Sciences. APASL working party on Liver Fibrosis. Dedicated to Excellence in Patient Care, Teaching & Research in Liver & Biliary Diseases. Five years after the first consensus: what is new and what we need?. Dr. S K Sarin

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Institute of Liver & Biliary Sciences

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  1. APASL STC CAIRO 2014 Institute of Liver & Biliary Sciences APASL working party on Liver Fibrosis Dedicated to Excellence in Patient Care, Teaching & Research in Liver & Biliary Diseases Five years after the first consensus: what is new and what we need? Dr. S K Sarin shivsarin@gmail.com A Deemed University Vasant Kunj, New Delhi, India www.ilbs.in

  2. ILBS : Residents

  3. ILBS : Faculty

  4. I have no particular talent…I am merely inquisitive

  5. APASL – Hepatic Fibrosis Working Party Meeting: New Delhi June 11-13, Cairo Making of Guidelines 2014 PurposeProcess Level of evidenceGrade of recommendation

  6. STEP 2 Selection of experts by the APASL Working Party on Hepatic Fibrosis STEP 3 Prioritize Issues STEP 4 Assigning issues to a group of experts for systemetic review STEP 5 Circulation of the systemic reviews and draft consensus based on evidence and recommendations

  7. Purpose of Guidelines • To assist physicians, patients, health-care providers, and health-policy makers worldwide in informed decision-making process according to evidence based data. • Where all resources and therapies are available. • Adapt to local needs, capacities and costs • Research

  8. Then and Now: Evidence Based 2008 2014 and Beyond GRADE system • Oxford syatem

  9. Grade Classification: level of evidence

  10. GRADE System

  11. GRADE System

  12. Hepatic Fibrosis: Assessment 2008 2014 and beyond Liver Biopsy qFibrosis, CPA (Collagen Proportion area) Portal Pressure/ HVPG Correlation with fibrosis , New classification, outcome Computerized Endoscopic Manometery, Variceal Pressure Monitor • Liver Biopsy • Fibrosis Semi-Quantification • HVPG • Correlation with Fibrosis

  13. Hepatic Fibrosis: Assessment 2008 2014 and Beyond Non-invasive Markers APRI, Fibrotest, ELF, Fibrospect Fibrometer, Fibrofast Fib4, Forn’s Index NAFLD Fibrosis Score (Age, BMI, diabetes/IGTT, Platelet, Alb, AST/ALT ratio • Non-invasive markers • APRI, ELF (EuropenanLiv Fib) • Fibrotest, Fibrospect • Hepascore • Fibrometer • Fibrofast

  14. Hepatic Fibrosis: Serum Markers 2008 2014 Serum Markers + vWF CK18 • Serum Markers • Hyaluronic acid, MMP3 inhibitor, PIIIP, laminin

  15. Hepatic Fibrosis: Assessment 2008 2014 Non Invasive Microbubble US CEUS Fibroscan CAP LSM Spleen stiffness Liver spleen ratio ARFI SSWE MR elastography Breath tests 13C Methacetin BT • Non invasive • Doppler • Microbubble US • CEUS • Fibroscan

  16. Reversibility of Hepatic Fibrosis 2014 Fibrosis regression not synonymous with reversibility of cirrhosis Significant fibrosis reduction/reversal NASH cirrhosis (post-metabolic surgery) HBV (Tenofovir), • Fibrosis regression not synonymous with reversibility of cirrhosis • Architecture, vascular shunts ,function don’t return to normal

  17. Hepatic Fibrosis: Serum Markers • Serum Markers • Hyaluronic acid, MMP3 inhibitor, PIIIP, laminin • Serum Markers + • vWF • CK18

  18. Hepatic Fibrosis: New Therapies • Therapies- Inhibitors • Loxl2 (Gilead) • TGFαv6 – STX100 • Pirfenidone (TGF , p38) • LPA1 – (fibroblast migration) • IL4, IL13 (tralokinumab) • Agonists • PRM-151 (Amyloid P) agonist, resolves fibrosis

  19. Challenges • Time short, AASLD • Challenges • End-points of fibrosis assessment not clear • Biomarkers, breath tests – not there • Pathobiology and genesis of fibrosis !

  20. What we want to achieve in Cairo ! • Systematic reviews in each area needed • General, disease based, Rewrite most of the articles • GRADE system, Evidence based • APASL recommendations purposeful, • Include some, could not attend

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