Ferruccio Bonino

Background/Objectives: The current cornerstone for prognostic hepatocellular carcinoma (HCC) stratification is the Barcelona Clinic Liver Cancer (BCLC) score, which integrates tumor and liver function staging but lacks tumor biology parameters. Serum tumor biomarkers, such as alpha-fetoprotein (AFP), protein induced by vitamin K absence-II (PIVKA-II), and glypican-3 (GPC-3), may improve prognostic assessment. We evaluated their prognostic value in this multicenter retrospective study. Methods: Serum AFP, PIVKA-II, and GPC-3 levels were measured (as continuous and categorical variables: >20 ng/mL, >200 mAU/mL, and >150 pg/mL, respectively) at baseline in 605 consecutive patients newly diagnosed with HCC at two tertiary Italian centers (2010–2024). The correlation between tumor stage, liver function, tumor marker levels, and overall survival (OS) was analyzed using Kaplan–Meier and Cox proportional hazards models. Results: Tumor marker levels increased stepwise across BCLC stages. Median OS was 29.0 months, declining from 47.9 months (BCLC-0) to 10.7 months (BCLC-C; p < 0.001). In univariate analysis, shorter OS was significantly (p < 0.001) associated with elevated serum levels of all tumor markers, higher ALBI grade, presence of ascites, and portal hypertension. On multivariate analysis, BCLC stage, ascites (hazard ratio [HR] 2.19, p < 0.001), ALBI grade 2–3 (HR 1.36, p = 0.009), and PIVKA-II > 200 mAU/mL (HR 1.56, p < 0.001) were independently associated with OS, whereas GPC-3 showed a borderline association (HR 1.27, p = 0.058), but not AFP (HR 0.88; p = 0.306). Conclusions: In this multicenter retrospective cohort study, PIVKA-II was the only serum biomarker independently associated with OS after adjusting for BCLC stage and liver function. These findings support further prospective evaluation of whether PIVKA-II provides clinically meaningful incremental prognostic information beyond established BCLC-based assessment.

Background: Small intestine bacterial overgrowth (SIBO) is associated with steatohepatitis (SH) in subjects with metabolic-associated steatotic liver disease (MASLD). The impact of ileocecal valve (ICV) incontinence, a major cause of SIBO in patients with MASLD, remains unknown because of the unmet need for a non-X-ray-dependent diagnosis. Methods: Exploiting water as contrast medium and colonic irrigation via a hydro-colon machine (Clean Colon Srl, Monza, Italy), we developed a new abdominal ultrasound (US) procedure for diagnosing and grading ICV incontinence. In a pilot, observational, feasibility and safety study, we correlated a new ICV incontinence parameter with irritable bowel syndrome (IBS, ROMA IV criteria), serum transaminases (AST, ALT), platelet counts, FIB-4, US liver steatosis and stiffness (LS, measured by Shear Wave and Transient Elastography, SWE and TE). Results: We prospectively studied 32 consecutive subjects with IBS who underwent a pre-colonoscopy colon cleansing after informed consent: 19 males (59%), body mass index (BMI) 26.6 ± 2.6 kg/m², age 57 ± 19 years, 16 (50%) with US liver steatosis. The half-hour (27 min, range 20–35 min) procedure was safe and well tolerated except in two males with prostate hypertrophy. ICV incontinence was graded (after 2500–3000 mL irrigation) according to cecum/right-colon distention with/without (immediate or delayed) reflux into terminal ileum (TI): 0 = cecum distension without TI reflux; 1 = cecum distension with TI reflux; 2 = absence of cecum distension with TI reflux. Cecum/right-colon distention (grade 0 or 1) was perceived by the patients whereas the right colon irrigation with complete ICV incontinence (grade 2) was symptomless. ICV continence associated with LS (p ≤ 0.0001). A histologic diagnosis of non-alcoholic steatohepatitis was confirmed in a 35-year-old obese male with SIBO and LS > 8 kPa (8.7/8.5 kPa by SWE/TE):steatosis (grade S3) with hepatocyte ballooning, lobular inflammation (grade 6/8) without fibrosis (stage 0/4, F0). Conclusions: The new US-based approach provides a feasible, easy-to-perform, mini-invasive tool for the diagnosis and grading of ICV incontinence. Preliminary results prompt prospective studies investigating the impact of ICV incontinence as a possible co-factor of steatohepatitis in patients with MASLD.

Background: Gut dysbiosis may trigger inflammation and steatohepatitis (SH) in subjects with metabolic associated steatotic liver disease (MASLD). Both incidence and impact of ileocecal valve (ICV) dysfunction as cause of small intestine bacterial overgrowth in MASLD remain unknown because of the unmet need of non-radiology dependent diagnostic procedures. Methods: Exploiting water as contrast medium and a hydro colon machine (Clean Colon Srl, Monza, Italy) for automated retrograde gentle colonic irrigation, we developed a new abdominal ultrasound procedure for diagnosis of ICV incontinence and we present the results of a pilot feasibility study for the assessment of its relationship with triggering of inflammation in steatotic liver disease. Results: Consecutive patients (32) performing colonic irrigation in colonoscopy preparation underwent concomitant abdominal ultrasound examination. Patients were predominantly males (59%) with body mass index (BMI) 26,6±2,6 kg/m2 and liver steatosis was present in half of the patients. Liver stiffness was 26,6±2,6 kPa, while serum transaminases ALT and AST were 33,1±9,5 and 25,9±8,4 U.I., respectively. The procedure that lasted a mean of 27min (range 20-35 min) was well tolerated in all, but 2 males with large prostate hypertrophy. Three ICV continence patterns (A - Early reflux, already at small water volume without evident cecum distension; B - Late reflux, after evident cecum distension; C - No reflux, either early or late after overall water irrigation and significant cecum distension) were observed during water irrigation (4266 ml mean, range 2000-8000 ml). ICV continence was significantly associated with IBS, steatosis, and liver stiffness (all p ≤ 0.0001). Furthermore, IBS (OR 3.97), steatosis (OR 3.30), and liver stiffness (OR 2.43 per unit increase) were also independently associated with dichotomization of impaired ICV continence.A 35-year-old male with SIBO and LS = 8.7 kPa underwent a liver biopsy showing histologically-determined high level of steatosis (S3), hepatocyte ballooning, lobular inflammation (Grade 6/8) in absence of fibrosis (Stage 0/4 F0).Conclusion: This proof-of-concept study indicates that an easy and quick mini-invasive diagnosis of ICV incontinence is feasible using water as contrast medium during abdominal ultrasound examination. Preliminary results suggest that this new technique is worth of being validated in prospective studies investigating the impact ICV incontinence as possible co-factor of steatohepatitis in patients with MAFLD.

Background and Aims: Virologic profiling is mandatory for the clinical management of hepatitis B surface antigen (HBsAg) carriers, positive for antibody against hepatitis delta virus (anti-HDV). We analyzed the correlations between serum HDV RNA, anti-HDV, HBV markers, and liver disease in a single-center cohort study. Approach and Results: Virologic, biochemical, imaging/histologic characteristics were studied in 146 consecutive HBsAg/anti-HDV carriers at baseline; in 31 interferon-treated patients, HDV/HBV markers were measured at the end of therapy (EOT), 24 weeks after EOT, and at the end of follow-up (EOF). HDV RNA was quantified with the Altostar-Quantification-Kit (Altona Diagnostics) and anti-HDV by 10-fold endpoint dilutions (Liaison XL Murex anti-HDV, DiaSorin). Liver disease was absent in 9/10 (90%) HDV RNA negative/anti-HDV–positive (all ≤1:100) and 2/136 (1.5%) viremic individuals (HDV RNAp =0.004], viremia peaking in early [6.02 (5.21−6.56) Log IU/mL] versus advanced cirrhosis [5.44 (4.71−6.06) Log IU/mL, p =0.006]. HDV RNA correlated with anti-HDV, HBsAg, HBcrAg, and ALT ( p p =0.003), ALT (β=0.220, p =0.001), and HBsAg levels (β=0.515, p <0.001). All but one of the 16 IFN responders had anti-HDV≤1:100 at EOF; all relapsers/non-responders had anti-HDV≥1:1000. Conclusions: Combined HDV RNA and anti-HDV quantification provides complementary information for characterizing HBV/HDV infection and monitoring treatment response. Declining anti-HDV levels are associated with virological control. These results prompt prospective multicentre studies of their role in the clinical and therapeutic management of patients with HBV/HDV coinfection.

Background: Steatotic liver disease (SLD) is a growing global health concern and may progress to more advanced liver diseases (i.e., fibrosis, cirrhosis, and hepatocellular carcinoma). Early identification of individuals at risk through effective screening strategies is crucial for timely intervention and management. The aim of this population-based study was to evaluate the feasibility of mean/large-scale screening and its importance by analyzing key risk factors, such as metabolic and lifestyle-related determinants. Methods: This cross-sectional study involved 387 subjects aged 18 to 89 years in a remote rural area that stretches among the valleys at the foot of the Apennines and the Apuan Alps. Anthropometric and demographic data were recorded, together with the measurement of blood pressure and cardiac rhythm. Furthermore, US-based liver stiffness (LS) and the ultrasound attenuation parameter (UAP) using the ILivTouch (Hisky Medical, Wuxi, China) device were performed. All data were analyzed with SPSS version 28. Univariate and multivariate analyses were conducted to identify significant predictors of both LS and UAP. Results: Significant associations are observed between elevated LS and UAP values and risk factors, such as BMI and waist circumference (BMI and waist with R = 0.45 and R = 0.34, R = 0.29 and R = 0.28; respectively, for UAP and LS; all with p < 0.001). The presence of hypertension is associated with a high value of LS (p < 0.05), and high UAP with alcohol consumption and sugary coffee intake habit (p < 0.001 and, p < 0.05, respectively). Conclusions: General population screening for SLD is feasible, sustainable, and useful to identify both individuals at risk and patients with progressive liver disease.

The availability of highly effective direct-acting antivirals (DAAs) that cure individuals infected with HCV has changed completely the natural history of HCV infection and chronic hepatitis C. In sustained responders to DAAs, the most common clinical-pathologic outcome has become liver disease regression, cirrhosis re-compensation, and the de-listing of transplant candidates. However, careful scrutiny of liver disease cofactors and outcome predictors in treated patients is mandatory for an appropriate personalized surveillance of the residual risk for hepatocellular carcinoma. Since successful treatment with DAAs does not confer protective immunity against HCV reinfection, an effective vaccine is critically needed to control HCV infection. Meanwhile, it is mandatory to enhance universal access to DAAs, to test asymptomatic high-risk groups who are the main source of transmission, and to screen people who inject drugs (PWID), men who have sex with men (MSM), and sex workers, and to assure safe medical procedures with the provision of disposable needle and syringes.

MiRNAs circulating in whole serum and HBsAg-particles are differentially expressed in chronic hepatitis B (CHB) and HBeAg-negative-HBV infection (ENI); their profiles are unknown in chronic hepatitis D (CHD). Serum- and HBsAg-associated miRNAs were analyzed in 75 subjects of 3 well-characterized groups (CHB 25, CHD 25, ENI 25) using next-generation sequencing (NGS). Overall miRNA profiles were consonant in serum and HBsAg-particles but significantly different according to the presence of hepatitis independently of Hepatitis D Virus (HDV)-co-infection. Stringent (Bonferroni Correction < 0.001) differential expression analysis showed 39 miRNAs upregulated in CHB vs. ENI and 31 of them also in CHD vs. ENI. miRNA profiles were coincident in CHB and CHD with only miR-200a-3p upregulated in CHB. Three miRNAs (miR-625-3p, miR-142-5p, and miR-223-3p) involved in immune response were upregulated in ENI. All 3 hepatocellular miRNAs of MiR-B-Index (miR-122-5p, miR-99a-5p, miR-192-5p) were overexpressed in both CHB and CHD patients. In conclusion, CHD and CHB patients showed highly similar serum miRNA profiling that was significantly different from that of individuals with HBeAg-negative infection and without liver disease.

Hepatitis B “e” antigen (HBeAg) negative chronic hepatitis B (CHB), 40 years since discovery in the Mediterranean area, has become the most prevalent form of HBV-induced liver disease worldwide and a major health care burden caused by HBV infection. A great deal of knowledge accumulated over the last decades provides consistent evidence on the bimodal dynamics of the expression of structural and non-structural forms of the viral core proteins which associate with different virologic and clinic–pathologic outcomes of HBV infection. In absence of serum HBeAg, the presence and persistence of HBV replication causes and maintains virus-related liver injury. Thus, in clinical practice it is mandatory to screen HBV carriers with HBeAg-negative infection for the early diagnosis of HBeAg-negative CHB since antiviral therapy can cure HBV-induced liver disease when started at early stages.

Until SARS-CoV-2 vaccination consolidates immunity worldwide, infectious strains will continue to cause infection, causing critical pressures on the healthcare systems and lockdowns. To improve decision-making strategies and prediction based on epidemiological data, so far biased by highly-variable testing criteria, an algorithm using unbiased morbidity parameters, i.e. Intensive Care Units (ICU) and Ordinary Hospitalization (HO), is proposed. ICU/HO acceleration and velocities are mathematically modeled using official available data to yield two thresholds, alerting on 30% ICU and 40% HO of COVID-19 daily occupancy settled by the Italian Minister of Health, as a case of study. A predictive model is also proposed to estimate the daily occupancy of ICU and HO in hospitals for each region, using a Susceptible-Infected-Recovered-Death (SIRD) epidemic model to further extend occupancy prediction in each regional district. Computed data validated the proposed models in Italy after more than one-year of pandemic obtaining agreements with the Italian Presidential Decree, regardless of the different regional trends of epidemic waves. Therefore, the decision-making algorithm and prediction model resulted valuable tools, retrospectively, to be tested prospectively in sustainable strategies to curb the impact of COVID-19, or of any other pandemic threats with any aggregate of data, on the local healthcare systems.