Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Splenic stiffness measurement combined with liver stiffness measurement compared with Baveno VII criteria in predicting the presence of Oesophageal and Gastric varices in patients with compensated advanced liver cell disease (cALCD)(Cureus, 2024) De Silva, A.P.; Niriella, M.A.; Nishad, N.; Jayasundara, H.; Jayasena, H.; Samarawickrama, V.T.; Ranawaka, C.; Basnayake, K.; De Silva, S.T.; De Silva, H.J.INTRODUCTION Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD).METHODS Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored.RESULTS One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices.CONCLUSION Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices.Item “What’s in a name?”–The implications of change in nomenclature for fatty liver disease from NAFLD to MAFLD to MASLD(The Sri Lanka Medical Association, 2024) Niriella, M.A.No abstract availableItem Mistakes in the management of iron deficiency anaemia: A narrative review(Taylor & Francis, 2024) Niriella, M.A.; Jayasena, H.; Withanachchi, A.; Premawardhena, A.INTRODUCTION Anaemia occurs due to an imbalance between erythrocyte production and loss. This imbalance can be due to ineffective erythropoiesis, blood loss or haemolysis. Whilst there are many causes for anaemia, iron deficiency anaemia (IDA) remains the predominant cause worldwide.AREAS COVERED: There have been many updated guidelines on the management of IDA in the past few years. As the reasons for IDA are many, evaluation requires thorough analysis and focused investigations. As an asymptomatic disease in the early stages, IDA can lead to many mistakes in its management. This review highlights potential mistakes in assessing and managing IDA and recommendations to avoid them.CONCLUSION The effective management of IDA necessitates a comprehensive and multidisciplinary approach. By recognising and addressing the common mistakes highlighted in this narrative review, healthcare professionals can improve patient outcomes, minimise complications, and enhance the overall quality of care.Item Herbal treatments for non-alcoholic fatty liver disease: A systematic review and meta-analysis of randomized controlled trials(Elsevier Ltd, 2024) Rathnayake, D.W.; Sooriyaarachchi, P.; Niriella, M.A.; Ediriweera, D.; Perera, J.BACKGROUND With the rising prevalence of non-alcoholic fatty liver disease (NAFLD), there is a growing need to explore alternative therapeutic interventions. This study aimed to comprehensively evaluate the available evidence from randomized controlled trials (RCTs) for the use of herbal medications in NAFLD.METHODS A literature search was conducted in PubMed, Web of Science and Scopus databases using appropriate keywords for studies published before the 6th of July 2023. RCTs involving humans, with confirmed NAFLD, the intervention group (IG) receiving herbal treatment, the control group (CG) given a placebo, participants aged ≥18 years, published in English, and a Jadad score ≥6 were included. Coffee and green tea as interventions were excluded. A meta-analysis of studies examining the effects of herbal supplementation on clinical and biochemical parameters in patients with NAFLD was performed. Analysis was done with the “meta” package in R programming language version 4.3.RESULTS In this analysis encompassing 48 articles, study durations varied from 6 weeks to 12 months, with sample sizes ranging between 36 and 226 patients. The study included a total of 3741 patients, (IG=2013, CG=1728). Predominant single herbal medicines identified were Phyllanthus niruri, Beta vulgaris, Allium sativum L., Silymarin (Silybum marianum), Portulaca oleracea L., Nigella sativa, and Cynara cardunculus L. Meanwhile, Cynara cardunculus and curcumin were the most common ingredients in polyherbal compounds. Meta-analysis outcomes revealed a higher reduction in alanine aminotransferase (ALT), aspartate aminotransferase (AST), liver stiffness, waist circumference (WC), weight, body mass index (BMI), triglycerides (TG), and fasting blood glucose (FBG) in the IG compared to the CG. Notably, the reductions in ALT and weight were more pronounced in single herb compounds compared to polyherbal compounds. No differences were observed between the two groups regarding HbA1c levels.CONCLUSION These findings highlight the potential benefits of herbal interventions with regard to improvements in anthropometry, metabolic profiles, and liver enzymes in study participants.Item APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure.(Springer, 2024) Maiwall, R.; Singh, S.P.; Angeli, P.; Moreau, R.; Krag, A.; Singh, V.; Singal, A.K.; Tan, S.S.; Puri, P.; Mahtab, M.; Lau, G.; Ning, Q.; Sharma, M.K.; Rao, P.N.; Kapoor, D.; Gupta, S.; Duseja, A.; Wadhawan, M.; Jothimani, D.; Saigal, S.; Taneja, S.; Shukla, A.; Govil, D.; Pandey, G.; Madan, K.; Eapen, C.E.; Benjamin, J.; Chowdhury, A.; Salao, V.; Yang, J.M.; Hamid, S.; Shalimar; Jasuja, S.; Kulkarni, A.V.; Niriella, M.A.; Tevethia, H.V.; Arora, V.; Mathur, R.P.; Roy, A.; Jindal, A.; Saraf, N.; Verma, N.; Arka, D.; Choudhary, N.S.; Mehtani, R.; Chand, P.; Rudra, O.; Sarin, S.K.; Puri, P.; Singh, S.Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.Item Assessing motivation to lose weight: the psychometric properties of the Sinhala version of University of Rhode Island Change Assessment (URICA) scale(Sri Lanka Medical Association, 2023) Niriella, M.A.; de Silva, S.T.; Hapangama, A.; Baminiwatta, A.; Fernando, R.; Ediriweera, D.INTRODUCTION: Weight reduction through lifestyle modifications is an important component in the management of various chronic diseases. The degree of motivation to change has been shown to predict outcomes in weight reduction interventions. Thus, the availability of a validated self-report tool assessing the degree of motivation for weight management would be useful for both clinical and research purposes in Sri Lanka. OBJECTIVES: To examine the structural validity and internal consistency of the URICA for weight management in a sample of Sri Lankan adults with chronic medical conditions. METHODS: Standard procedures for cross-cultural adaptation of a questionnaire were followed in translating the 32-item URICA into Sinhala. The Sinhala version was administered to 208 patients aged 18-60 years attending outpatient clinical services for non-disabling chronic medical diseases. Psychometric testing included confirmatory factor analysis and the assessment of internal consistency (Cronbach α). RESULTS: The commonly accepted four-factor structure of URICA reflecting Prochaska and Di Clemente’s transtheoretical model (pre-contemplation, contemplation, action and maintenance) showed good model fit, after the removal of four items from the pre-contemplation subscale due to inadequate factor loadings (<0.4). In line with theory, factor correlations indicated that the pre-contemplation factor was inversely correlated with the other three factors, while the other three factors were positively correlated with one another. All four subscales showed good internal consistency (Cronbach α ranging from 0.73 to 0.89). CONCLUSIONS: The Sinhala version of a modified 28-item URICA was found to have sound psychometric properties as a measure of motivation for weight management among Sinhala-speaking adult patient.Item Assessing reversibility of liver fibrosis in patients with transfusion-dependent beta thalassaemia following intensive chelation(Sri Lanka Medical Association, 2023) Padeniya, A.G.P.M.; Ediriweera, D.; Niriella, M.A.; de Silva, A.; Premawardhena, A.P.INTRODUCTION: Transfusion-related iron overload is a leading cause of hepatic fibrosis in transfusion-dependent thalassaemia (TDT). OBJECTIVES: This study aimed to evaluate the reversibility of liver fibrosis with intensive chelation therapy in TDT. METHODS: Forty-five patients were included. Serum ferritin, hepatic fibrosis & steatosis (assessed by Transient Elastography), and liver iron concentration/LIC (estimated by FerriScan) were recorded at recruitment and after 2 ½ years of intensive chelation. Compliance for iron chelators was monitored and recorded as good (gc), moderate compliance (mc), and poor (pc) compliance based on the number of days the iron chelators were used. RESULTS: 22/45 (49%) were males [mean age (SD)-19 (4.78) years]. There were 23 (51%), 12 (27%), and 10 (22%) patients with gc, mc, and pc with iron chelators, respectively. The LIC decreased in 36 (80%) patients. The median LIC reduction after 2 ½ years was as follows: gc group-13.5 to 5.1 mg Fe/g dw (P=0.0002); mc group-25.5 to 17.75 mg Fe/g dw (P=0.001). In the pc group, the LIC increased by 10.4 mg Fe/g dw (P =0.058). Liver fibrosis declined in 23 (51%) patients. The liver stiffness at recruitment and after 2 ½ years was 7.6 and 7.1 kPa (P=0.08) in the gc group. In both mc and pc groups, liver fibrosis increased on follow-up [significantly worsened in the pc group (P=0.04)]. CONCLUSION: The reduction of LIC in TDT was related to compliance with chelation therapy; substantial reductions were achieved in those with gc and mc. However, only those with gc managed to arrest the fibrosis progression.Item Is splenic stiffness measurement(SSM) better than Baveno VII criteria to predict oesophageal and cardio- fundal varices in patients with compensated advanced liver cell disease (cACLD)?(Sri Lanka Medical Association, 2023) de Silva, A.P.; Niriella, M.A.; Nishad, A.A.N.; Samarawickrama, V.T.; Jayasundara, H.; Ranawaka, C.K.; de Silva, S.T.; Withanage, M.; Ediriweera, D.; de Silva, H.J.INTRODUCTION: Liver and splenic stiffness measurements (LSM and SSM) using transient elastography (TE) are being increasingly used as a screening tool to predict varices. OBJECTIVES: We aimed to test the utility of Baveno-VII criteria (LSM>25kPa, LSM>20kPa with platelet count <130,000 and LSM>15kPa with platelet count <110,000) and SSM to predict oesophageal and cardio-fundal varices in a cohort of Sri Lankan patients with aALCD. METHODS: Consecutive patients with newly diagnosed Child’s class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent upper gastrointestinal endoscopy by an endoscopist followed by a Fibroscan by an operator who is unaware of endoscopy findings using ECHOSENS-Fibroscan-502 to measure LSM and SSM. Validity measurements of three Baveno-VII criteria and SSM values to predict oesophageal and cardio-fundal varices were calculated. RESULTS: One hundred and seventy-four individuals were recruited [Mean (95%CI) age 61.4 (59.7-62.8) years, 110 males], and 106 had varices. Our results indicate that the three Baveno VII criteria had sensitivities of 61%, 63% and 42%, and specificities of 79%, 77% and 87%. SSM>30kPa alone or in combination with LSM>15kPa had sensitivity of 81&75%, specificity of 72&83%, PPV of 82&87%, NPV of 71&67% and accuracy of 78&78% consecutively to predict oesophageal and cardio-fundal varices. CONCLUSION: Baveno VII criteria had low sensitivity but high specificity to predict oesophageal and cardio-fundal varices. SSM>30kPa alone or in combination with LSM>15kPa seemed to predict oesophageal and cardio-fundal varices better.Item Genetic and metabolic aspects of non-alcoholic fatty liver disease (NAFLD) pathogenicity(Springer, 2023) Samarasinghe, S.M.; Hewage, A.S.; Siriwardana, R.C.; Tennekoon, K.H.; Niriella, M.A.; de Silva, S.BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease showing a risingprevalence globally. Genetic predisposition plays a key role in the development and progression of the disease pathogenicity. MAIN BODY: This paper summarizes genetic associations based on their influence on several metabolic aspects such as lipid metabolism, glucose metabolism, hepatic iron accumulation and cholesterol metabolism toward the NAFLD pathogenicity. Furthermore, we present variations in some epigenetic characters and the microRNA profile with regard to NAFLD. CONCLUSION: As reported in many studies, the PNPLA3 rs738409 variant seems to be significantly associated with NAFLD susceptibility. Other gene variants like TM6SF2 rs58542926, MBOAT7 rs641738 and GCKR variants also appear to be more prevalent among NAFLD patients. We believe these genetic variants may provide insights into new trends in developing noninvasive biomarkers and identify their suitability in clinical practice in the future.Item Prevalence and associated factors for non-alcoholic fatty liver disease among adults in the South Asian Region: a meta-analysis(Elsevier, 2023) Niriella, M.A.; Ediriweera, D.S.; Withanage, M.Y.; Darshika, S.; de Silva, S.T.; de Silva, H.J.BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the commonest chronic liver disease worldwide. We estimated the prevalence and predefined associated factors for NAFLD among South-Asian adults. METHODS: We searched PubMed and included descriptive, epidemiological studies with satisfactory methodology, reporting the prevalence of NAFLD with ultrasound. Two authors screened and extracted data independently. Gender, urban/rural settings, general population and individuals with metabolic diseases (MetD) stratified the analysis. In addition, a random-effects meta-analysis of the prevalence and effect sizes of associations of NAFLD was performed. FINDINGS: Twenty-two publications were included after the quality assurance process. The difference in the NAFLD prevalence between the general population and people with MetD was found to be statistically significant (Q = 15.8, DF = 1, P < 0.001). The pooled overall prevalence of NAFLD in the general population was 26.9% (95% CI: 18.9-35.8%) with high heterogeneity. The prevalence was similar among men and women (Q = 0.06, DF = 1, P = 0.806). The NAFLD prevalence in the rural communities was 22.6% (95% CI: 13.6-33.1%), and the prevalence in urban communities was 32.9% (95% CI: 22.8-43.8%) and the difference was not statistically significant (Q = 1.92, DF = 1, P = 0.166). The pooled overall prevalence of NAFLD in patients with MetD was 54.1% (95% CI: 44.1-63.9%) with high heterogeneity. The pooled overall prevalence of NAFLD in the non-obese population was 11.7% (95% CI: 7.0-17.3%). The pooled prevalence of non-obese NAFLD in the NAFLD population was 43.4% (95% CI: 28.1-59.4%). Meta-analysis of binary variables showed that NAFLD in the South Asian population was associated with diabetes mellitus, hypertension, dyslipidaemia, general obesity, central obesity and metabolic syndrome. Gender was not associated with NAFLD. INTERPRETATION: The overall prevalence of NAFLD among adults in South Asia is high, especially in those with MetD, and a considerable proportion is non-obese. In the South Asian population, NAFLD was associated with diabetes mellitus, hypertension, dyslipidaemia, general obesity, central obesity, and metabolic syndrome.