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Lysosomal Acid Lipase: Can it be a New Non-Invasive Serum Biomarker of Cryptogenic Liver Fibrosis and Cirrhosis?
Marta Gravito-Soares
,**,,
Corresponding author
ms18498@gmail.com

Correspondence and reprint request:
, Elisa Gravito-Soares*,**,, Dario Gomes*,**, Luis Tome*,**
* Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
** Faculty of Medicine, University of Coimbra, Coimbra, Portugal
Authors contributed equally to this work
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currently represents a well-stablished and validated non-invasive method for assessing both fibrosis and steatosis&#44; with high accuracy when compared to liver biopsy&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">2&#44;3</span></a> Several noninvasive serum biomarkers&#47;scores have been emerging to evaluate the presence of significant fibrosis&#44; some of them involving multiple variables and expensive markers &#40;a2-macroglobulin&#44; hyaluronic acid&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">Lysosomal acid lipase &#40;LAL&#41; is an enzyme that plays a key role in lipid metabolism&#44; responsible for triglycerides and cholesterol esters hydrolysis through the low-density lipoprotein &#40;LDL&#41;-receptor pathway&#46; Reduced LAL activity leads to accumulation of cholesterol esters in lyso-somes&#46; Genetically-determined LAL deficiency with a severe reduction &#40;&#60; 0&#46;03 nmol&#47;spot&#47;h&#41; occurs in Wolman disease and cholesterol ester storage diseases<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">5-8</span></a> by LIPA gene mutations encoding LAL&#44; namely the E8SJM variant &#40;50&#37;-70&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">9&#44;10</span></a> These conditions are associated with a severe liver steatosis and liver failure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a> Current knowledge about the role of LAL activity besides these genetic diseases is very scarce&#46; Recent literature has found an association between reduced LAL activity and non-alcoholic fatty liver disease &#40;NAFLD&#41;&#47;non-alcoholic steato-hepatitis &#40;NASH&#41;&#44; possibly related to metabolic syndrome&#44; which is characteristic of most of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">5&#44;8&#44;9&#44;11</span></a> In addition&#44; some studies have shown an association between reduced LAL activity and liver cirrhosis of any cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10&#44;11</span></a> However&#44; in the presence of a well-known liver disease it is difficult to determine whether reduced LAL activity is the cause or consequence of liver injury itself or whether it is determined by the liver disease-causing agent&#46; Recent studies have also shown that LAL activity is reduced in cryptogenic cirrhosis&#44; although with no clear relationship between them&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10&#44;11&#44;13</span></a> Despite one study in pediatric population&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a> there are no studies concerning LAL activity in adult patients with abnormal liver enzymes and different degrees of fibrosis besides advanced liver disease &#40;cirrhosis&#41;&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">The aims of this study are&#58;</p><p id="p0025" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0030" class="elsevierStylePara elsevierViewall">To determine the association of LAL activity with cryptogenic steatosis and with different degrees of cryptogenic fibrosis in patients with unexplained persistent abnormal liver enzymes&#46;</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0035" class="elsevierStylePara elsevierViewall">To assess the presence of the E8SJM mutation in patients with LAL activity below the upper limit of the carrier range&#46;</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">&#8226;</span><p id="p0040" class="elsevierStylePara elsevierViewall">To evaluate the determinants of reduced LAL activity in these patients&#46;</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">&#8226;</span><p id="p0045" class="elsevierStylePara elsevierViewall">To determine the predictive power of LAL activity for liver steatosis&#44; significant fibrosis and cirrhosis compared to other non-invasive and non-expensive conventional biomarkers&#46;</p></li></ul></p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Materials and Methods</span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Patients</span><p id="p0050" class="elsevierStylePara elsevierViewall">A cross-sectional observational study of 101 consecutive adult patients with unexplained abnormal liver enzymes&#44; who attended to the Gastroenterology Department of the Centro Hospitalar e Universitario Coimbra between November 2014 and June 2017&#46; Inclusion criteria were as follows&#58;</p><p id="p0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0015"><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">&#8226;</span><p id="p0060" class="elsevierStylePara elsevierViewall">All outpatients and inpatients aged &#62; 18 years&#46;</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0065" class="elsevierStylePara elsevierViewall">Persistent abnormal liver enzymes &#40;&#62; 6 months&#41; or hepatomegaly of unknown etiology with or without dyslipidemia &#40;hypercholesterolemia and&#47;or hypertriglyceridemia&#41;&#46;</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">&#8226;</span><p id="p0070" class="elsevierStylePara elsevierViewall">An exhaustive liver study workup to rule out the most common causes of abnormal liver enzymes&#58; anti-HCV&#44; anti-HBs&#44; anti-HBc&#44; anti-HAV&#44; anti-HEV antibodies&#44; HBs-Ag&#59; antinuclear &#40;&#60; 1&#58;80&#41;&#44; anti-mitochondrial&#44; anti-smooth muscle and anti-liver and kidney microsomal antibodies&#59; ferritin and transferrin saturation &#40;&#60; 40&#37;&#41;&#44; serum levels of ceruloplasmin and alpha-1 antitrypsin&#59; serum levels of immunoglobulins IgA&#44; IgG and IgM&#59; anti-tissue transglutaminase IgA and serum protein electrophoresis&#46;</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">&#8226;</span><p id="p0075" class="elsevierStylePara elsevierViewall">The presence of an abdominal ultrasound with measurement and recording of the highest longitudinal distance between the dome of the liver&#47;spleen and the tip &#40;splenic&#47;liver length&#44; in cm&#41;&#46;</p></li></ul></p><p id="p0080" class="elsevierStylePara elsevierViewall">Exclusion criteria included well-stablished risk factors for NAFLD&#47;NASH&#44; such as obesity &#40;body mass index &#62; 30 kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a>&#41;&#44; type 2 diabetes and metabolic syndrome&#44; significant alcohol consumption &#40;&#62; 20 g&#47;day if woman and &#62; 30 g&#47;day if man&#41;&#44; use of drugs-induced liver injury or hepatocellular carcinoma&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">Seventy-one patients underwent liver biopsy or Fibro-Scan<span class="elsevierStyleSup">&#174;</span> to assess the presence of steatosis and fibrosis&#44; and categorization of fibrosis degree &#40;<a class="elsevierStyleCrossRef" href="#f0010">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0090" class="elsevierStylePara elsevierViewall">Etiological investigation of fibrosis&#47;cirrhosis was based on standard clinical&#44; laboratory and histologic findings&#46; For the purpose of this study&#44; cryptogenic cirrhosis was defined as cirrhosis of unknown etiology in the absence of significant alcohol consumption&#44; well-stablished risk factors for NAFLD&#47;NASH or other known causes of chronic liver disease&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">All patients enrolled in this study agreed to participate and signed informed consent&#46; The study was approved by the Ethics Committee of our hospital&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Methods</span><p id="p0100" class="elsevierStylePara elsevierViewall">Demographic&#44; clinical and laboratory data were recorded for each patient&#46; Laboratory parameters included alanine aminotransferase&#44; aspartate aminotransferase&#44; alkaline phosphatase&#44; gamma-glutamyl transferase&#44; total bilirubin&#44; international normalized ratio&#44; albumin&#44; platelet count and lipid profile &#40;total-cholesterol &#40;C&#41;&#44; high-density lipoprotein &#40;HDL&#41;-C&#44; estimated LDL-C&#44; triglycerides&#41;&#46; The study population was evaluated according to LAL activity&#46; Additionally&#44; patients were categorized into three subgroups based on the presence of liver steatosis&#44; significant fibrosis and cirrhosis&#44; and the differences between these subgroups were evaluated&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Determination of LAL activity</span><p id="p0105" class="elsevierStylePara elsevierViewall">For all patients&#44; a 5cc fresh venous blood sample was collected into ethylenediaminetetraacetic acid tube&#44; after 12 hours of fasting&#46; The blood sample was distributed to fill all four circles in a filter paper &#91;Whatman &#35;903 card for dried blood spot testing &#40;DBS&#41; by Hamilton J&#44; <span class="elsevierStyleItalic">et al&#44;</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> according to the requirements of the National Committee for Clinical Laboratory Standard Protocol&#46; After drying overnight at room temperature&#44; the samples were stored in a resealable plastic ziplock bag with desiccant at -20&#175;C and analyzed within 1 week after collection&#46; LAL activity was determined using the inhibitor Lalistat-2 &#40;Cheschire&#44; CT&#44; USA&#41; and expressed in nmol&#47;spot&#47;h of 4-Methylumbelliferone&#46; The reference range considered for normal LAL activity was 0&#46;37-2&#46;30 nmol&#47;spot&#47;h&#44; since it was the reference range of the laboratory that analyzed our DBS-LAL activity samples &#40;Biochemistry Department&#44; Queen Elizabeth University Hospitals&#44; Glasgow&#44; UK&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> Heterozygous carriers were considered for LAL activity between 0&#46;15 and 0&#46;40 nmol&#47;spot&#47;h&#44; which corresponds to an intermediate activity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a></p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">E8SLM mutation analysis in LIPA gene</span><p id="p0110" class="elsevierStylePara elsevierViewall">In case of reduced LAL activity&#44; a second sample was collected using DBS and the mean between the two determinations was considered&#46; If LAL activity &#60; 0&#46;40 nmol&#47; spot&#47;h&#44; an additional collection of fresh venous blood &#40;4x ethylenediaminetetraacetic acid tubes of 2&#46;7 mL&#41; was performed and stored at -80&#175;C&#46; Sample analysis was then completed using DNA extraction and determination of E8JSM mutation &#40;SNP rs116928232 G&#62;A&#41; &#40;Instituto Nacional de Saude Doutor Ricardo Jorge&#44; Lisboa&#44; Portugal&#41;&#46; The cut-off 0&#46;40 nmol&#47;spot&#47;h was chosen to guarantee higher sensitivity by including heterozygous carriers in addition to patients with LAL activity &#60; 0&#46;03 nmol&#47;spot&#47;h &#40;homozygous&#41;&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Steatosis and fibrosis assessment</span><p id="p0115" class="elsevierStylePara elsevierViewall">Patients who underwent liver biopsy &#40;74&#46;6&#37;&#59; n &#61; 53&#41; or FibroScan&#174; &#40;25&#46;4&#37;&#59; n &#61; 18&#41; were included&#46; Quality of liver measurements was guaranteed&#44; since all liver samples had at least 11 portal spaces for liver biopsy&#59; and a median value of at least 10 successful measurements with an interquartile range &#60; 30&#37; from the median and success rate &#62; 60&#37; for FibroScan&#174;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> In liver biopsy&#44; steatosis was considered if was present in &#62; 10&#37; of hepatocytes<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> &#40;macrovesicular&#44; microvesicular or mixed&#41; and fibrosis according to the METAVIR classification&#44; categorized as significant &#40;&#62; F2&#41; or cirrhosis &#40;F4&#41;&#46; In FibroScan&#174;&#44; steatosis was considered if controlled attenuation parameter &#62; 280dB&#47;m<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a> and fibrosis for elastography cut-off values of 7&#46;1kPa to &#62; F2 and 12&#46;5kPa to F4&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a>&#8217;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a> For cirrhotic patients&#44; liver function scores Child-Turcotte-Pugh &#40;CTP&#41; and Model for end-stage liver disease-sodium &#40;MELD-Na&#41; scores were also evaluated&#46; Risk factors for steatosis&#44; significant fibrosis and cirrhosis were determined by comparison with patients without these conditions&#46; In addition&#44; the predictive power of LAL activity for significant fibrosis&#47;cirrhosis was also assessed by comparison with other common serum biomarkers&#47;tests such as FIB4&#44; APRI and GUCI&#46; These biomarkers were chosen since they are non-invasive&#44; non-expensive and easy to use&#44; as stated in recent EASL guidelines with an accuracy to predict significant fibrosis above 83&#46;3&#37; &#40;the accuracy achieved for LAL activity in our study to predict significant fibrosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a></p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Statistical analysis</span><p id="p0120" class="elsevierStylePara elsevierViewall">Statistical analysis was carried out using the social package for social sciences&#44; version 22&#46;0 for Windows &#40;Chicago&#44; IL&#44; USA&#41;&#46; The level of significance was set at p-value less than 0&#46;05&#46; Continuous data were expressed as mean and SD and compared using Student&#8217;s t-test if normality was verified or Mann-Whitney test if no normality&#46; Categorical variables were expressed as percentage and compared using x<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a>-test if normality was confirmed or Fisher&#8217;s exact probability test if there was no normality&#46; Multivariate logistic regression analysis was used to study the influence of independent variables on reduced LAL activity&#46; Area under the receiver operating characteristic curve &#40;AUROC&#41; was applied in the evaluation of predictive ability of LAL activity and other known non-invasive biomarkers for steatosis&#44; significant fibrosis and cirrhosis&#44; assigning the best cut-off in terms of sensitivity and specificity&#46;</p></span></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Results</span><p id="p0125" class="elsevierStylePara elsevierViewall">The study was conducted in 101 inpatients and outpatients with persistently abnormal liver enzymes and&#47;or unexplained hepatomegaly with&#47;without dyslipidemia&#44; after common liver diseases have been ruled out&#46;</p><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Characterization of study population and determinants of reduced LAL activity</span><p id="p0130" class="elsevierStylePara elsevierViewall">Of all patients&#44; median LAL activity was 0&#46;35&#40;0&#46;21-0&#46;48&#41; mmol&#47;spot&#47;h &#40;minimum&#58; 0&#46;05&#59; maximum&#58; 1&#46;06&#41; with a predominance of female gender &#91;61&#46;4&#37; &#40;n &#61; 62&#41;&#93; and mean age of 58&#46;0 &#177; 17&#46;3 years old&#46; Concerning liver enzymes&#44; patients presented a slight elevation of transaminases &#40;aspartate aminotransferase&#58; 41&#46;7 &#177; 27&#46;0IU&#47;L&#59; N &#60; 35IU&#47;L&#41;&#59; alanine aminotransferase&#58; 50&#46;2 &#177; 35&#46;6IU&#47;L&#59; N &#60; 45IU&#47;L&#41; and mean gamma-glutamyl transferase of 158&#46;6 &#177; 143&#46;2IU&#47;L &#40;N &#60; 55IU&#47;L&#41;&#46; Fifty patients &#40;49&#46;5&#37;&#41; showed dyslipidemia with slight elevation of total-C &#40;mean&#58; 200&#46;8 &#177; 91&#46;5 mg&#47;dL&#59; N &#60; 200 mg&#47;dL&#41; and triglycerides &#40;mean&#58; 156&#46;2 &#177; 162&#46;0 mg&#47;dL&#59; N &#60; 150mg&#47;dL&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0135" class="elsevierStylePara elsevierViewall">Fifty-four patients &#40;53&#46;5&#37;&#41; had reduced LAL activity by DBS&#44; who were compared with patients with normal LAL activity&#46; The two groups were comparable in terms of age and gender&#46; After univariate analysis&#44; risk factors related to reduced LAL activity were the presence of significant liver fibrosis &#40;66&#46;7&#37; <span class="elsevierStyleItalic">vs&#46;</span> 20&#46;7&#37;&#59; p &#60; 0&#46;001&#41;&#44; cirrhosis &#40;59&#46;5&#37; <span class="elsevierStyleItalic">vs&#46;</span> 10&#46;3&#37;&#59; p &#60; 0&#46;001&#41; and splenomegaly &#40;29&#46;6&#37; <span class="elsevierStyleItalic">vs&#46;</span> 6&#46;4&#37;&#59; p &#61; 0&#46;002&#41; with 1&#46;26-fold increased spleen size &#40;14&#46;4 &#177; 12&#46;1 <span class="elsevierStyleItalic">vs&#46;</span> 11&#46;4 &#177; 2&#46;4&#59; p &#61; 0&#46;037&#41;&#46; Regarding biochemical parameters&#44; patients with reduced LAL activity had a higher international normalized ratio &#40;1&#46;34 &#177; 0&#46;56 <span class="elsevierStyleItalic">vs&#46;</span> 1&#46;16 &#177; 0&#46;22&#59; p &#61; 0&#46;013&#41;&#44; lower white blood cell count &#40;WBC&#41; &#40;5&#46;5 &#177; 1&#46;8 <span class="elsevierStyleItalic">vs&#46;</span> 6&#46;7 &#177; 1&#46;5&#59; p &#61; 0&#46;001&#59; N&#58;4-10&#42;109&#47;L&#41; and platelet count &#40;160&#46;8 &#177; 83&#46;8 <span class="elsevierStyleItalic">vs&#46;</span> 231&#46;8 &#177; 81&#46;4&#59; p &#60; 0&#46;001&#59; N&#58;150-400&#42;109&#47;L&#41;&#46; After a multivariate analysis of significant variables in univariate analysis&#44; risk factors associated with reduced LAL activity were cirrhosis &#40;OR 13&#46;7&#59; p &#60; 0&#46;001&#41; and low WBC &#40;OR 1&#46;35&#59; p &#61; 0&#46;002&#41;&#46; No significant differences were found between two groups relatively to liver size&#44; steatosis&#44; dyslipidemia or lipid profile&#46; Among cirrhotic patients&#44; those with reduced LAL activity did not present more severe liver dysfunction determined by CTP and MELD-Na scores&#44; when compared with cirrhotic patients with normal LAL activity &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>&#41;&#46;</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Risk factors for steatosis&#44; significant fibrosis and cirrhosis</span><p id="p0140" class="elsevierStylePara elsevierViewall">Among the patients who underwent liver biopsy or FibroScan&#174;&#44; 62&#46;0&#37; &#40;n &#61; 44&#41; presented steatosis&#44; 47&#46;9&#37; &#40;n &#61; 34&#41; significant fibrosis and 39&#46;4&#37; &#40;n &#61; 28&#41; cirrhosis&#46; Median LAL activity was reduced in the three subgroups&#46; Moreover&#44; median LAL activity was lower among patients with significant fibrosis &#40;82&#46;4&#37;&#59; n &#61; 28&#59; median LAL activity&#58; 0&#46;22 &#40;0&#46;11-0&#46;29&#41; <span class="elsevierStyleItalic">vs&#46;</span> 0&#46;40 &#40;0&#46;34-0&#46;51&#41;&#59; p &#60; 0&#46;001&#41; and cirrhosis &#40;89&#46;3&#37;&#59; n &#61; 25&#59; median LAL activity&#58; 0&#46;21&#40;0&#46;11-0&#46;27&#41; <span class="elsevierStyleItalic">vs&#46;</span> 0&#46;40 &#40;0&#46;32-0&#46;52&#41;&#59; p &#60; 0&#46;001&#41; than patients without these conditions&#46; However&#44; there was no association between LAL activity and steatosis &#40;0&#46;36 &#40;0&#46;21-0&#46;46&#41; <span class="elsevierStyleItalic">vs&#46;</span> 0&#46;29 &#40;0&#46;20-0&#46;47&#41;&#59; p &#61; 0&#46;558&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 2</a> and <a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0145" class="elsevierStylePara elsevierViewall">As reported in <a class="elsevierStyleCrossRef" href="#t0015">Table 2</a>&#44; after a multivariate analysis of the statistically significant variables in univariate analysis&#44; a positive association was found between liver steatosis and dyslipidemia &#40;OR &#61; 5&#46;0&#59; p &#61; 0&#46;001&#41;&#46; In addition&#44; significant fibrosis was positively associated with splenomegaly &#40;OR11&#46;0&#59; p &#61; 0&#46;006&#41;&#44; total bilirubin &#40;OR &#61; 7&#46;2&#59; p &#61; 0&#46;022&#41; and reduced LAL activity &#40;OR &#61; 4&#46;1&#59; p &#61; 0&#46;022&#41;&#59; and inversely with platelet count &#40;OR &#61; 1&#46;013&#59;p &#61; 0&#46;003&#41; and LAL activity &#40;OR &#61; 1&#46;006&#59; p &#61; 0&#46;014&#41;&#46; Among patients with cirrhosis&#44; a positive association was verified with splenomegaly &#40;OR &#61; 13&#46;3&#59; p &#61; 0&#46;002&#41;&#44; reduced LAL activity &#40;OR &#61; 12&#46;6&#59; p &#61; 0&#46;004&#41; and total bilirubin &#40;OR &#61; 7&#46;2&#59; p &#61; 0&#46;042&#41;&#44; and a negative association with platelet count &#40;OR &#61; 1&#46;010&#59; p &#61; 0&#46;005&#41; and LAL activity &#40;OR &#61; 1&#46;005&#59; p &#61; 0&#46;003&#41;&#46;</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">E8SJM mutation in LIPA gene</span><p id="p0150" class="elsevierStylePara elsevierViewall">Sixty-five patients &#40;64&#46;4&#37;&#41; had LAL activity &#60; 0&#46;40 nmol&#47;spot&#47;h&#46; These patients were tested to E8SJM mutation in LIPA gene&#46; However&#44; none of them was homozygous or heterozygous for this mutation&#46;</p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">LAL activity among patients with cirrhosis and severity of liver disease</span><p id="p0155" class="elsevierStylePara elsevierViewall">In multivariate analysis&#44; LAL activity as a categorical or continuous variable was independently associated with cirrhosis &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 2</a>&#41;&#46; Despite of median LAL activity be lower in cirrhotic patients than in patients with significant fibrosis&#44; there was no association between LAL activity and liver dysfunction&#44; assessed by CTP &#40;p &#62; 0&#46;05 for CTP B or C compared with CTP A&#41; and MELD-Na &#40;r<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a> &#61; 0&#46;003&#59; p &#61; 0&#46;632&#41; &#40;<a class="elsevierStyleCrossRef" href="#f0020">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="f0020"></elsevierMultimedia></span><span id="s0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Predictive power of LAL activity for steatosis&#44; significant fibrosis and cirrhosis</span><p id="p0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#f0025">Figure 4</a> shows a lack of association between LAL activity and steatosis &#40;AUROC &#61; 0&#46;536&#59; p &#61; 0&#46;558&#41;&#46; However&#44; LAL activity showed a strongly positive association with significant fibrosis &#40;AUROC &#61; 0&#46;833&#59; p &#60; 0&#46;001&#41; for a cut-off of 0&#46;265 &#40;sensitivity &#61; 84&#46;6&#37;&#59; specificity &#61; 74&#46;1&#37;&#41; and with cirrhosis &#40;AUROC &#61; 0&#46;859&#59;p &#61; &#60; 0&#46;001&#41; for a cut-off of 0&#46;235 &#40;sensitivity &#61; 86&#46;2&#37;&#59; specificity &#61; 75&#46;0&#37;&#41;&#46; LAL activity was superior to other non-expensive conventional biomarkers in predicting significant fibrosis and cirrhosis &#40;FIB4&#58; &#62; F2-AUROC &#61; 0&#46;797&#59; p &#60; 0&#46;001&#44; F4-AUROC &#61; 0&#46;755&#59; p &#60; 0&#46;001&#59; GUCI&#58; &#62; F2-AUROC &#61; 0&#46;742&#59; p &#61; 0&#46;001&#44; F4-AUROC &#61; 0&#46;726&#59; p &#61; 0&#46;001&#59; APRI&#58; &#62; F2-AUROC &#61; 0&#46;694&#59; p &#61; 0&#46;006&#59; F4-AUROC &#61; 0&#46;682&#59;p &#61; 0&#46;008&#41;&#46;</p><elsevierMultimedia ident="f0025"></elsevierMultimedia></span></span><span id="s0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0110">Discussion</span><p id="p0165" class="elsevierStylePara elsevierViewall">Our study expands knowledge about the influence of LAL activity on liver disease by adding paramount findings about this non-genetic test&#44; as an independent non-invasive serum biomarker of significant fibrosis and cirrhosis in patients with persistent abnormal liver enzymes of unknown etiology with higher accuracy than other non-expensive conventional biomarkers&#46; There was no correlation between LAL activity and cryptogenic steatosis after well-stablished risk factors for NAFLD&#47;NASH have been ruled out&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">For the first time&#44; our study determined independent factors associated with reduced LAL activity in an adult population with persistently abnormal liver enzymes of unknown etiology with different degrees of fibrosis beyond cirrhosis&#46; A positive and independent correlation was observed between reduced LAL activity and cryptogenic liver cirrhosis&#44; also verified by other works&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10&#44;11</span></a> probably in relation to others factors transverse to cirrhosis of any etiology not yet recognized&#46; However&#44; our median LAL activity for cryptogenic cirrhosis was lower than in other works &#40;0&#46;21 <span class="elsevierStyleItalic">vs&#46;</span> 0&#46;49-0&#46;62&#41;&#44; which was comprised within heterozygous carrier range&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10&#44;11</span></a> Like other studies&#44; low WBC was also a determinant of DBS-determined LAL activity in multivariate analysis&#44; probably because LAL mainly comes from leucocytes and the enzymatic activity is normalized to spot diameter and not to protein concentration in DBS&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">8&#44;17&#44;18</span></a> However&#44; Vespasiani-Gentilucci&#44; <span class="elsevierStyleItalic">et al&#46;</span> only considered cirrhotic patients which may have influenced the low WBC as a consequence of portal hypertension and splenomegaly&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a></p><p id="p0175" class="elsevierStylePara elsevierViewall">Since platelets contain lysosomes&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> several studied attempted to evaluate the correlation between LAL activity and platelet count&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">7&#44;8&#44;18</span></a> Some studies suggested that LAL activity could be in relation with platelet count in a cirrhosis context&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">7&#44;8</span></a> and more recently&#44; in healthy subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> However&#44; our study performed in patients with different degrees of fibrosis beyond cirrhosis showed no association between LAL activity and platelet count&#44; suggesting the involvement of other unknown mechanisms in LAL activity reduction for cryptogenic fibrosis&#47;cirrhosis&#46;</p><p id="p0180" class="elsevierStylePara elsevierViewall">Additionally&#44; since steatosis and fibrosis are the major determinants of liver dysfunction progression regardless of liver disease etiology&#44; the authors also determined the factors associated with steatosis and significant fibrosis&#46;</p><p id="p0185" class="elsevierStylePara elsevierViewall">Concerning liver steatosis&#44; there was an association with dyslipidemia&#46; In fact&#44; only studies evaluating the relationship between LAL activity and cirrhosis by NAFLD&#47;NASH have been performed&#44; where the association with steatosis is undoubted&#46; Despite the association of dyslipidemia in patients with NAFLD&#47;NASH and LAL activity&#44; some studies have reported an association with a high total-C and LDL-C&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">6&#44;20</span></a> suggesting that a reduction in lipid droplet clearance by lysosomal pathway could lead to accumulation of both esterified and non-esterified cholesterol in hepatocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> However&#44; it remains unknown whether the reduction of circulating LAL activity is susceptible to cause a significant reduction in liver LAL activity&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">22</span></a> Indeed&#44; our study found a correlation between LAL activity and significant fibrosis&#47; cirrhosis subgroups but not with steatosis subgroup&#46; This fact may be related to the exclusion of patients with well-stablished risk factors to NAFLD&#47;NASH&#44; including obesity&#44; type 2 diabetes and metabolic syndrome&#46; In NAFLD&#47;NASH background&#44; LAL activity can be modulated by these risk factors and not by NAFLD&#47; NASH condition per se&#46; Even in studies with a large number of patients with cryptogenic cirrhosis&#44; most patients had obesity &#40;mean body mass index of 30&#46;9 &#177; 7&#46;8 Kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a>&#41; and type 2 diabetes &#40;68&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">7&#44;11</span></a> both conditions strongly associated with the presence and progression of NAFLD&#47;NASH&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">4&#44;5</span></a> For the first time&#44; authors evaluated the role of LAL activity in patients without well-stablished risk factors for NAFLD&#47;NASH&#44; and no association was found with dyslipidemia or lipid profile&#46; This suggests that only non-atherogenic form of dyslipidemia may be related to reduced LAL activity&#44; contrarily to atherogenic dyslipidemia&#44; which was associated with NAFLD&#47;NASH&#44; characterized by hypertriglyceridemia&#44; low HDL-C and high LDL-C&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">12&#44;23</span></a> In order to evaluate the predictive power of LAL activity in liver steatosis subgroup&#44; no association was evidenced through multivariate and AUROC analyses&#44; suggesting that the association with steatosis in other studies was a result of NAFLD&#47;NASH etiology of cirrhosis and metabolic syndrome<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">6&#44;7</span></a> and not due to steatosis without these features&#46;</p><p id="p0190" class="elsevierStylePara elsevierViewall">Our study also describes&#44; for the first time in adult patients&#44; the role of LAL activity and other factors as determinants of significant fibrosis beyond cirrhosis&#46; A study in pediatric population found a significant lower LAL activity in children with significant fibrosis than those with mild fibrosis&#46; However they did not have cirrhotic children in study population and therefore did not assess differences between significant fibrosis and cirrhosis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a> In addition to LAL activity&#44; other factors such as splenomegaly&#44; high total bilirubin and low platelet count were independently associated with both significant fibrosis and cirrhosis&#46; These parameters represent indirect markers of cirrhosis due to portal hypertension and hypersplenism&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">7&#44;14</span></a> However&#44; these factors were also related to significant fibrosis&#44; suggesting that these factors are already present at an early stage of fibrosis progression&#44; although with higher expression in cirrhosis&#46; Despite a good correlation between reduced LAL activity and fibrosis degree&#44; this correlation was independent of liver function&#46; According to pathophysiology&#44; reduced LAL activity could be a mere consequence of overall decrease of viable hepatocytes and subsequently less protein synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a> Additionally&#44; some studies have shown that lysosomal-associated natural killer cells were crucial in preventing fibrosis progression in liver disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">24&#44;25</span></a> However&#44; LAL activity was not correlated with liver dysfunction assessed by CTP and MELD-Na scores&#44; as demonstrated in another study with the evaluation of one of these scores&#44; the CTP score&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">7&#44;11</span></a> This fact suggests that mechanisms related to the reduction of LAL activity are associated with the fibrosis process and not with liver function&#46; Like Vespasiani-Gentilucci&#44; <span class="elsevierStyleItalic">et al&#44;</span> and contrarily to Baratta&#44; <span class="elsevierStyleItalic">et al</span>&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> no association was found between LAL activity and transaminase levels&#46; Nonetheless&#44; Baratta&#44; <span class="elsevierStyleItalic">et al</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> only evaluated patients with NAFLD&#47;NASH where the inflammatory component plays an important role given its association with insulin resistance&#44; a central feature of metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> Since LAL activity was independently related to significant fibrosis and cirrhosis&#44; our study also evaluated the predictive power of LAL activity in their prediction&#46; Currently&#44; there are no specific biomarkers&#47;tests for fibrosis or cirrhosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> For the first time&#44; LAL activity was compared to other known non-invasive and non-expensive fibrosis biomarkers&#47;tests&#46; The strongest predictor for significant fibrosis with an AU-ROC of 0&#46;833 &#40;p &#60; 0&#46;001&#41; and most striking for cirrhosis with an AUROC of0&#46;859 &#40;p &#60; 0&#46;001&#41; for a cut-off of 0&#46;265 nmol&#47;spot&#47;h and 0&#46;235 nmol&#47;spot&#47;h respectively&#44; which fits the heterozygous carrier range of LAL activity&#46; This fact suggests that in patients with unexplained abnormal liver enzymes&#44; LAL activity below 0&#46;265 nmol&#47;spot&#47;h is strongly related to the presence of significant fibrosis and when LAL activity falls below 0&#46;235 nmol&#47;spot&#47;h makes the presence of cirrhosis very likely&#46;</p><p id="p0195" class="elsevierStylePara elsevierViewall">Additionally&#44; as Vespasiani-Gentilucci&#44; <span class="elsevierStyleItalic">et al</span>&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a> the reduction of LAL activity in patients with significant fibrosis and cirrhosis was probably acquired and not genetically determined&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> since the major mutation of LIPA gene was not found&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">27&#44;28</span></a> Furthermore&#44; in an adult population with a suspected clinical and laboratory context of cholesterol ester storage diseases&#44; screening for LIPA gene mutation should be performed to a threshold below the upper limit of heterozygous carrier range in case of significant fibrosis or cirrhosis&#46; However&#44; if reduced LAL activity is a cause or consequence of significant fibrosis and cirrhosis remains to be determined&#46;</p><p id="p0200" class="elsevierStylePara elsevierViewall">The limitations of this study included&#58;</p><p id="p0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0020"><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">&#8226;</span><p id="p0210" class="elsevierStylePara elsevierViewall">The cross-sectional study design&#44; and therefore&#44; the impossibility to establish a cause-effect relationship between reduced LAL activity and the presence of cryptogenic significant fibrosis or cirrhosis&#46;</p></li><li class="elsevierStyleListItem" id="u0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0215" class="elsevierStylePara elsevierViewall">A single-center study&#46;</p></li><li class="elsevierStyleListItem" id="u0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0220" class="elsevierStylePara elsevierViewall">Fibrosis and steatosis were evaluated by 2 different techniques &#40;liver biopsy and FibroScan&#174;&#41;&#44; but the majority of patients performed liver biopsy &#40;almost 3&#47;4&#41; and FibroScan<span class="elsevierStyleSup">&#174;</span> is a validated tool to accurately assess fibrosis and steatosis&#44; significantly reducing the heterogeneity of study population&#46;</p></li></ul></p><p id="p0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; our study has many strengths&#58;</p><p id="p0230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0025"><li class="elsevierStyleListItem" id="u0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0235" class="elsevierStylePara elsevierViewall">The exclusion of potential confounders through a multivariate logistic analysis&#46;</p></li><li class="elsevierStyleListItem" id="u0070"><span class="elsevierStyleLabel">&#8226;</span><p id="p0240" class="elsevierStylePara elsevierViewall">The evaluation of LAL activity determinants to properly interpret the results in subgroups of steatosis&#44; significant fibrosis and cirrhosis&#46;</p></li><li class="elsevierStyleListItem" id="u0075"><span class="elsevierStyleLabel">&#8226;</span><p id="p0245" class="elsevierStylePara elsevierViewall">The evaluation of LAL activity determinants for different degrees of liver fibrosis&#46;</p></li><li class="elsevierStyleListItem" id="u0080"><span class="elsevierStyleLabel">&#8226;</span><p id="p0250" class="elsevierStylePara elsevierViewall">The comparison&#44; for the first time&#44; between LAL activity and other conventional biomarkers&#47;tests to assess liver fibrosis&#46;</p></li></ul></p><p id="p0255" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study highlights that the reduction of LAL activity appears to occur on an acquired-basis for significant fibrosis and cirrhosis at levels &#60; 0&#46;40 nmol&#47; spot&#47;h&#46; LAL activity &#60; 0&#46;265 nmol&#47;spot&#47;h was strongly associated with cryptogenic significant fibrosis and &#60; 0&#46;235 nmol&#47;spot&#47;h with cryptogenic cirrhosis&#46; Contrarily&#44; no correlation was found between LAL activity and cryptogenic liver steatosis in the absence of well stablished risk factors for NAFLD&#47;NASH&#46; LAL enzyme seems to be a new non-invasive serum biomarker of cryptogenic liver fibrosis with higher accuracy than conventional known biomarkers&#47;tests&#46;</p><p id="p0260" class="elsevierStylePara elsevierViewall">Further prospective multicenter studies are needed to understand the role of LAL in liver fibrogenesis and its underlying mechanisms related to the progression of cryptogenic fibrosis to cirrhosis&#46;</p></span><span id="s0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0115">Abbreviations</span><p id="p0265" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0030"><li class="elsevierStyleListItem" id="u0085"><span class="elsevierStyleLabel">&#8226;</span><p id="p0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">AUROC</span>&#58; area under receiver operating characteristic curve&#46;</p></li><li class="elsevierStyleListItem" id="u0090"><span class="elsevierStyleLabel">&#8226;</span><p id="p0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">C</span>&#58; cholesterol&#46;</p></li><li class="elsevierStyleListItem" id="u0095"><span class="elsevierStyleLabel">&#8226;</span><p id="p0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CTP</span>&#58; Child-Turcotte-Pugh&#46;</p></li><li class="elsevierStyleListItem" id="u0100"><span class="elsevierStyleLabel">&#8226;</span><p id="p0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">DBS</span>&#58; dried blood spot testing&#46;</p></li><li class="elsevierStyleListItem" id="u0105"><span class="elsevierStyleLabel">&#8226;</span><p id="p0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HDL-C</span>&#58; high-density lipoprotein-cholesterol&#46;</p></li><li class="elsevierStyleListItem" id="u0110"><span class="elsevierStyleLabel">&#8226;</span><p id="p0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LAL</span>&#58; lysosomal acid lipase&#46;</p></li><li class="elsevierStyleListItem" id="u0115"><span class="elsevierStyleLabel">&#8226;</span><p id="p0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LDL</span>&#58; low density lipoprotein&#46;</p></li><li class="elsevierStyleListItem" id="u0120"><span class="elsevierStyleLabel">&#8226;</span><p id="p0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LDL-C</span>&#58; low-density lipoprotein-cholesterol&#46;</p></li><li class="elsevierStyleListItem" id="u0125"><span class="elsevierStyleLabel">&#8226;</span><p id="p0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MELD-Na</span>&#58; model for end-stage liver disease-sodium&#46;</p></li><li class="elsevierStyleListItem" id="u0130"><span class="elsevierStyleLabel">&#8226;</span><p id="p0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NAFLD</span>&#58; non-alcoholic fatty liver disease&#46;</p></li><li class="elsevierStyleListItem" id="u0135"><span class="elsevierStyleLabel">&#8226;</span><p id="p0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NASH</span>&#58; non-alcoholic steatohepatitis&#46;</p></li><li class="elsevierStyleListItem" id="u0140"><span class="elsevierStyleLabel">&#8226;</span><p id="p0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">WBC</span>&#58; white blood cell count&#46;</p></li></ul></p></span><span id="s0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0120">Ethical Disclosures</span><p id="p0330" class="elsevierStylePara elsevierViewall">Protection of human and animal subjects&#46;</p><p id="p0335" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="s0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0125">Confidentiality of Data</span><p id="p0340" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="s0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0130">Right to Privacy and Informed Consent</span><p id="p0345" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="s0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0135">Conflicts of Interest</span><p id="p0350" class="elsevierStylePara elsevierViewall">The authors declares that there is no conflict of interest regarding the publication of this article&#46;</p></span><span id="s0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0140">Source of Funding</span><p id="p0355" class="elsevierStylePara elsevierViewall">Authors have no source of founding to declare&#46;</p></span><span id="s0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0145">Author&#8217;s Contributions</span><p id="p0360" class="elsevierStylePara elsevierViewall">Marta Gravito-Soares and Elisa Gravito-Soares contributed equally to the patient recruitment&#44; study design&#44; data analysis and interpretation and wrote the manuscript&#59; Dario Gomes and Luis Tome followed up patients&#44; analyzed data&#44; interpreted results and revised the manuscript for the important intellectual content&#46;</p></span><span id="s0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0150">Guarantor of the Article</span><p id="p0365" class="elsevierStylePara elsevierViewall">Marta Gravito-Soares&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:15 [
        0 => array:3 [
          "identificador" => "xres1224786"
          "titulo" => "Abstract"
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            0 => array:1 [
              "identificador" => "abs0010"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1138852"
          "titulo" => "Key words"
        ]
        2 => array:2 [
          "identificador" => "s0010"
          "titulo" => "Introduction"
        ]
        3 => array:3 [
          "identificador" => "s0015"
          "titulo" => "Materials and Methods"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "s0020"
              "titulo" => "Patients"
            ]
            1 => array:2 [
              "identificador" => "s0025"
              "titulo" => "Methods"
            ]
            2 => array:2 [
              "identificador" => "s0030"
              "titulo" => "Determination of LAL activity"
            ]
            3 => array:2 [
              "identificador" => "s0035"
              "titulo" => "E8SLM mutation analysis in LIPA gene"
            ]
            4 => array:2 [
              "identificador" => "s0040"
              "titulo" => "Steatosis and fibrosis assessment"
            ]
            5 => array:2 [
              "identificador" => "s0045"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        4 => array:3 [
          "identificador" => "s0050"
          "titulo" => "Results"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "s0055"
              "titulo" => "Characterization of study population and determinants of reduced LAL activity"
            ]
            1 => array:2 [
              "identificador" => "s0060"
              "titulo" => "Risk factors for steatosis&#44; significant fibrosis and cirrhosis"
            ]
            2 => array:2 [
              "identificador" => "s0065"
              "titulo" => "E8SJM mutation in LIPA gene"
            ]
            3 => array:2 [
              "identificador" => "s0070"
              "titulo" => "LAL activity among patients with cirrhosis and severity of liver disease"
            ]
            4 => array:2 [
              "identificador" => "s0075"
              "titulo" => "Predictive power of LAL activity for steatosis&#44; significant fibrosis and cirrhosis"
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "s0080"
          "titulo" => "Discussion"
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        6 => array:2 [
          "identificador" => "s0085"
          "titulo" => "Abbreviations"
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          "identificador" => "s0090"
          "titulo" => "Ethical Disclosures"
        ]
        8 => array:2 [
          "identificador" => "s0095"
          "titulo" => "Confidentiality of Data"
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        9 => array:2 [
          "identificador" => "s0100"
          "titulo" => "Right to Privacy and Informed Consent"
        ]
        10 => array:2 [
          "identificador" => "s0105"
          "titulo" => "Conflicts of Interest"
        ]
        11 => array:2 [
          "identificador" => "s0110"
          "titulo" => "Source of Funding"
        ]
        12 => array:2 [
          "identificador" => "s0115"
          "titulo" => "Author&#8217;s Contributions"
        ]
        13 => array:2 [
          "identificador" => "s0120"
          "titulo" => "Guarantor of the Article"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-11-04"
    "fechaAceptado" => "2018-01-10"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec1138852"
          "palabras" => array:5 [
            0 => "LAL"
            1 => "Chronic liver disease"
            2 => "Fibrosis degree"
            3 => "E8SJM mutation"
            4 => "Serum biomarkers"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Introduction and aim</span>&#46; The association between lysosomal acid lipase &#40;LAL&#41; activity and liver steatosis or fibrosis is poorly studied&#46; The aim of our study was to determine the predictive power of LAL for cryptogenic liver steatosis and cryptogenic significant fibrosis&#47;cirrhosis&#46;</p><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Material and methods</span>&#46; Cross-sectional observational study of 101 adult patients with unexplained elevated liver enzymes&#47;hepatomegaly with or without dyslipidemia submitted to the determination of LAL activity and LIPA gene &#40;E8SJM-C&#46;894G&#94;A&#41; mutation&#46; Seventy-one patients underwent liver biopsy or FibroScan&#174;&#46; Patients with an identifiable liver dysfunction cause and well-stablished NAFLD&#47;NASH risk factors were excluded&#46; Predictors for liver steatosis&#44; significant fibrosis &#40;&#62; F2&#41; or cirrhosis &#40;F4&#41; were evaluated&#46;</p><p id="sp0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Results</span>&#46; Liver steatosis and fibrosis were mainly assessed by liver biopsy &#40;74&#46;6&#37;&#59; n &#61; 53&#41;&#46; Steatosis was present in 62&#46;0&#37; &#40;n &#61; 44&#41;&#44; significant fibrosis in 47&#46;9&#37; &#40;n &#61; 34&#41; and cirrhosis in 39&#46;4&#37; &#40;n &#61; 28&#41;&#46; The median LAL was 0&#46;36 &#40;0&#46;21-0&#46;46&#41;nmol&#47;spot&#47;h &#40;vs&#46; 0&#46;29 &#40;0&#46;20-0&#46;47&#41;&#59; p &#61; 0&#46;558&#41; for liver steatosis&#44; 0&#46;22 &#40;0&#46;11-0&#46;29&#41; nmol&#47;spot&#47;h &#40;vs&#46; 0&#46;40 &#40;0&#46;34-0&#46;51&#41;&#59; p &#60;0&#46;001&#41; for significant fibrosis and 0&#46;21 &#40;0&#46;11-0&#46;27&#41; nmol&#47;spot&#47;h &#40;vs&#46; 0&#46;40 &#40;0&#46;32-0&#46;52&#41;&#59; p &#60; 0&#46;001&#41; for cirrhosis&#46; No LIPA gene mutations were found&#46; LAL activity was the strongest predictor of significant fibrosis &#40;AUROC&#58; 0&#46;833&#59; p &#60; 0&#46;001&#41; with a cut-off of 0&#46;265 &#40;sensitivity&#58; 85&#46;9&#37;&#59; specificity&#58; 75&#46;0&#37;&#41; and cirrhosis &#40;AUROC&#58; 0&#46;859&#59; p &#60; 0&#46;001&#41; with a cut-off of 0&#46;235 &#40;sensitivity&#58; 86&#46;2&#37;&#59; specificity&#58; 75&#46;0&#37;&#41;&#44; being higher than FIB4&#44; GUCI or APRI&#46; However&#44; LAL activity was not associated with liver steatosis &#40;AUROC&#58; 0&#46;536&#59; p &#61;0&#46;558&#41;&#46;</p><p id="sp0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Conclusion</span>&#46; LAL activity can be considered a non-invasive new marker of cryptogenic liver fibrosis with higher accuracy than other known biomarkers&#46; LAL activity &#60; 0&#46;265 nmol&#47;spot&#47;h was strongly associated with cryptogenic significant fibrosis and &#60;0&#46;235 nmol&#47;spot&#47;h with cryptogenic cirrhosis&#46; LAL activity was not associated with cryptogenic liver steatosis&#46;</p></span>"
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          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Flow chart of the study design&#46;</p>"
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          "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">LAL activity in three study subgroups - liver steatosis&#44; significant fibrosis&#44; and cirrhosis&#46;</p>"
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          "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">LAL activity according to liver disease severity for cirrhotic patients-Child-Turcotte-Pugh &#40;CTP&#41; and fMELD-Na scores&#46;</p>"
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          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Area under the ROC curve &#40;AUROC&#41; of LAL activity and other non-invasive serum biomarkers according to the presence of liver steatosis&#44; significant fibrosis and cirrhosis&#46;</p>"
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        "fuente" => "<span class="elsevierStyleItalic">LAL&#58; lysosomal acid lipase&#46; CI&#58; confidence interval&#46; CTP&#58; Child-Turcotte-Pugh&#46; WBC&#58; white blood cell count&#46; AST&#58; aspartate aminotransferase&#46; ALT&#58; alanine aminotransferase&#46; GGT&#58; gama-glutamyl transferase&#46; AP&#58; alkaline phosphatase&#46; INR&#58; international normalized ratio&#46; C&#58; Cholesterol&#46; IQR&#58; Interquartile range&#46; pU&#58; p-value of univariate analysis&#59; pM&#58; p-value of multivariate analysis &#40;Forward LR method&#41;&#44; which was applied to significant variables in univariate analysis&#46;</span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">All patients &#40;n &#61; 101&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reduced LAL activity &#40;n &#61; 54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal LAL activity &#40;n &#61; 47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pU&#47;pM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multivariate Odds ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male gender&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;38&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;37&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;40&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;442&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;yo&#41;&#44; &#956; &#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#46;0 &#177; 17&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;8 &#177; 15&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#46;1 &#177; 11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;367&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Splenomegaly&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;18&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;29&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;6&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spleen size &#40;cm&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;0 &#177; 9&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;4 &#177; 12&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;4 &#177; 2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;037&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatomegaly&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;21&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;22&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;21&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;552&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver size &#40;cm&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8 &#177; 3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&#46;7 &#177; 3&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&#46;8 &#177; 3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;614&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laboratory parameters</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">WBC &#40;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;1 &#177; 1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5&#46;1 &#177; 1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;7 &#177; 1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;001&#47;0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#91;1&#46;07&#59;1&#46;99&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AST &#40;IU&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">41&#46;7 &#177; 27&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">47&#46;0 &#177; 22&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">57&#46;2 &#177; 37&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;494&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ALT &#40;IU&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">50&#46;2 &#177; 35&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">42&#46;8 &#177; 22&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">58&#46;7 &#177; 39&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;105&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">GGT &#40;IU&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">158&#46;6 &#177; 143&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Total bilirubin &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Platelets &#40;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Albumin &#40;g&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Lipid profile</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Dyslipidemia&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total-C &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">LDL-C &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">HDL-C &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Triglycerides &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">156&#46;2 &#177; 162&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166&#46;4 &#177; 204&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">144&#46;5 &#177; 91&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;516&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with liver biopsy&#47;FibroScan&#174; &#40;n &#61; 71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduced LAL activity &#40;n &#61; 42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal LAL activity &#40;n &#61; 29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">pU&#47;pM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multivariate Odds ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Steatosis&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;62&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;57&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;69&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;367&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Significant fibrosis &#40;&#62; F2&#41;&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;47&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;66&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;20&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cirrhosis &#40;F4&#41;&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;39&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;59&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;10&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47;&#60; 0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTP score &#40;A&#47;B&#47;C&#41;&#44; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#47;9&#47;3 &#40;22&#46;5&#37;&#47;12&#46;7&#37;&#47;4&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#47;8&#47;3 &#40;56&#46;0&#37;&#47;32&#46;0&#37;&#47;12&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#47;1&#47;0 &#40;66&#46;7&#37;&#47;33&#46;3&#37;&#47;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;350&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTP score&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7 &#177; 1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8 &#177; 1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;0 &#177; 1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;505&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MELD-Na score&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2 &#177; 4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;4 &#177; 4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;7 &#177; 3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;516&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2092136.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Univariate and multivariate analyses of study population according to LAL activity&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "t0015"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">LAL&#58; lysosomal acid lipase&#46; CI&#58; confidence interval&#46; WBC&#58; white blood cell count&#46; AST&#58; aspartate aminotransferase&#58; ALT&#58; alanine aminotransferase&#59; GGT&#44; gama-glutamyl transferase&#46; AP&#58; alkaline phosphatase&#46; INR&#58; international normalized ratio&#46; C&#58; cholesterol&#46; IQR&#58; Interquartile range&#46; pU&#58; p-value of univariate analysis&#59; pM&#58; p-value of multivariate analysis &#40;Forward LR method&#41;&#44; which was applied to significant variables in univariate analysis&#46; Adjusted odds ratio and 95&#37; interval confidence for multivariate analysis&#58; Steatosis&#58; Dyslipidemia OR &#61; 5&#46;0 &#91;1&#46;9&#59;13&#46;0&#93;&#46; Significant fibrosis&#58; Splenomegaly OR &#61; 11&#46;0 &#91;2&#46;0&#59;58&#46;8J&#59; Platelets OR &#61; 1&#44;013 &#91;1&#46;004&#59;1&#46;021J&#46; Reduced LAL activity OR &#61; &#60;&#46;1 &#91;1&#46;2&#59;13&#46;7J&#46; LAL activity OR &#61; 1&#46;006 &#91;1&#46;001&#46;1&#46;261&#93;&#44; Total bilirubin OR &#61; 7&#46;2 &#91;1&#46;3&#59;38&#46;9J&#46; Cirrhosis&#58; Splenomegaly OR&#61;13&#46;3 &#91;3&#46;3&#59;53&#46;4J&#46; Platelets OR &#61; 1&#46;010 &#91;1&#46;004&#46;1&#46;025&#93;&#44; Reduced LAL activity OR &#61; 12&#46;6 &#91;2&#46;3&#59;29&#46;2J&#46; LAL activity OR &#61; 1&#46;005 &#91;1&#46;002&#59;1&#46;025J&#46; Total bilirubin OR &#61; 7&#46;7 &#91;1&#46;1&#59;45&#46;9J&#46;</span>"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Steatosis &#40;n &#61; 44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pU&#47;pM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significant fibrosis &#40;n&#61;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pU&#47;pM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cirrhosis &#40;n &#61; 28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pU&#47;pM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male gender&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#40;36&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;532&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#40;44&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#40;39&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;371&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;yo&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;1 &#177; 18&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;705&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;2 &#177; 16&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;033&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#46;9 &#177; 16&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;008&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LAL activity &#40;nmol&#47;spot&#47;h&#41;&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;36 &#40;0&#46;21-0&#46;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;558&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;22 &#40;0&#46;11-0&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47;0&#46;014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;21 &#40;0&#46;11-0&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47;0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduced LAL activity&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#40;54&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;367&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#40;82&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47; 0&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#40;89&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47; 0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Splenomegaly&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#40;13&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;084&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#40;41&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&#47;0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#40;50&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#46;001&#47; 0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spleen size &#40;cm&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;0 &#177; 3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8&#177;2&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;003&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7 &#177; 13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hepatomegaly&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#40;27&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#40;17&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;589&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#40;10&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;154&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver size &#40;cm&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;9 &#177; 2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;5 &#177; 3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;892&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;0 &#177; 3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;144&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laboratory parameters</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">WBC &#40;10<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a>&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7 &#177; 1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;079&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1 &#177; 1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;036&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1 &#177; 1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;010&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AST &#40;IU&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;5 &#177; 29&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;963&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;2 &#177; 25&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;470&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total bilirubin &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Platelets &#40;10<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">9</span></a>&#47;L&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Lipid profile</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Dyslipidemia&#44; n&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total-C &#40;mg&#47;dL&#41;&#44; &#956; &#177; &#963;&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos