Proximity to clinical practice, standardization of protocols, and the pursuit of non-invasive tests characterize hepatology studies at IDOR
The liver, one of the largest and most vital organs in the human body, performs hundreds of crucial functions. Whether it’s metabolizing digested nutrients like proteins, fats, and glucose, detoxifying substances, or producing bile and synthesizing cholesterol, the liver has been recognized since the days of Ancient Egypt as a bridge between the digestive system and the bloodstream. However, the diseases that affect this organ are just as complex as its functions, often remaining silent and stemming from multifactorial issues within the body.
Hepatology, the medical field dedicated to understanding and treating liver diseases, has been a part of the Instituto D’Or de Pesquisa e Ensino (IDOR) research since its inception. At the time, it was a subfield within the Internal Medicine area, alongside Cardiology and Gastroenterology. However, the growth of the Institute in recent years has expanded its areas of study, and Hepatology now includes investigators from different states, developing many of its research lines in close connection with clinical care provided by the Rede D’Or, the largest private hospital network in Latin America.
Dr. Renata Perez, a researcher in hepatology at IDOR since its inception and a professor at the Federal University of Rio de Janeiro (UFRJ), has a long history of research in hepatitis C, a silent viral disease that can progress to cirrhosis and even cancer. Today, there are treatments with over 95% cure rates for patients. Currently, her primary research focuses on other areas, including non-alcoholic fatty liver disease, cirrhosis, and its complications, as well as non-invasive imaging and assessment methods for liver diseases.
Regarding non-alcoholic fatty liver disease, Dr. Perez explains that it affects about 30% of the population, with a small portion of these patients progressing to severe forms of the condition. Differentiating the risk and severity of cases non-invasively is a key objective in this field. She states, “It’s an important disease due to its prevalence. It affects a large portion of the population and almost everyone knows someone who has it. Our goal is to diagnose and stratify the severity of the disease using non-invasive methods, because in a high-prevalence disease it’s crucial to differentiate between patients who will progress to cirrhosis and those who will live with fatty liver without major complications,” explains the physician.
In the area of cirrhosis, Dr. Perez aims to analyze methods that can identify complications of the disease, such as encephalopathy and renal changes, at earlier stages. She emphasizes that cirrhosis is a complex condition, resulting from chronic liver damage caused by various liver diseases, and it can manifest at different levels of severity. “Evaluating liver function is crucial for prognosis and determining the need for transplantation. However, there’s no single test that directly assesses liver function, so we use a combination of variables and scores to better understand the severity of the disease. Depending on the score, hepatic insufficiency can be mild, moderate, or severe, and those in the latter category are eligible for transplantation. Being able to make this assessment helps us prioritize the most urgent cases.” She adds that cirrhosis is also associated with complications in other organs, and for that reason her investigations often collaborate with other specialties to gain a broader perspective on clinical cases.
In the field of imaging studies, the investigation complements other research lines and explores the contributions of imaging methods, such as magnetic resonance, over invasive procedures like liver biopsies for diagnosing and assessing the severity of cirrhosis and fatty liver disease. Specific studies in this area also include investigating the imaging of Gaucher’s disease, a rare genetic dysfunction.
An Integrated Network in Hepatology
Since IDOR’s expansion and the establishment of its new units in several Brazilian states, hepatology research has been able to broaden its goals and align its interests even more closely with the reach of Rede D’Or hospitals. This integration is a part of the ‘D’Or Hepatology initiative’, led by Dr. Raymundo Paraná and Dr. Ana Pittella, both IDOR researchers and doctors at Rede D’Or.
D’Or Hepatology is nationally uniting the hepatology services of several Rede D’Or hospitals with the goal of standardizing protocols and care routines. This not only aids in updating healthcare professionals and improving hospital care but also benefits IDOR’s research field by enabling multicenter inclusions and expanding the pool of patients eligible for studies nationwide.
The initiative also benefits the education sector. Currently, frequent scientific sessions in D’Or Hepatology are held to update professionals about the most relevant topics in the field. Additionally, the approval process for a medical residency program in hepatology at IDOR is underway, which will offer positions in Rio de Janeiro and Salvador, under the guidance of the same visionary physicians behind the D’Or Hepatology initiative.
Dr. Raymundo Paraná, the strategic director and technical leader of the Aliança Hospital in Salvador, already utilizes the D’Or Hepatology network in his research on hepatotoxicity through the Hepatox project, which he leads alongside Dr. Ana Pittella. “Hepatotoxicity is a significant issue in Brazil due to self-medication culture and a fragmented healthcare system, where patients see different doctors who don’t communicate nor reconcile medication prescriptions. Moreover, we have social media, which offers a multitude of therapeutic proposals involving herbs, hormones, etc., often scientifically unfounded but enticing to individuals in good faith. The internet and social media don’t always align news with the quality of the source, and well-intentioned individuals easily believe in promising proposals regarding body aesthetics improvement. This has led to new diseases, and here in Brazil there’s no database about the toxicity of popular local herbs, for example. There’s no system documenting the risk of toxicity for some widely prescribed medications as well”, Dr. Paraná illustrates.
Liver intoxication can have various origins. In Dr. Ana Pittella’s outpatient clinic at Quinta D’Or Hospital in Rio de Janeiro, most recruited patients suffer from medication toxicity, often caused by chemotherapy drugs. On the other hand, patients recruited by Dr. Paraná in Salvador often have issues due to excessive consumption of herbs through infusions or prescribed formulas. According to the latter physician, the Hepatox project has a significant service-oriented goal: to provide Rede D’Or doctors with information on whether or not to discontinue certain medications in patients with suspected liver toxicity. Dr. Paraná anticipates, “We will be able to understand the reality of hepatotoxicity in the country, and the idea is to generate a vast database for scientific publications. These pieces of information will have a fantastic social impact as they will be disseminated even in basic units of the public healthcare system.”
Dr. Paraná also conducts research on sarcopenia and its outcomes in liver diseases. Sarcopenia involves the reduction of strength and muscle mass in the human body, primarily occurring in older adults and being a predictor of failure regarding liver transplantation. He adds, “In Brazil, there’s no center dedicated to this study, so this line of research was created to fill that gap. Besides muscle loss, sarcopenia causes myosteatosis, which is associated with unfavorable outcomes in metabolic syndrome. This scenery is one of the main indications for liver transplantation in the Western world.”
Resilience During the Pandemic and New Horizons
During the COVID-19 pandemic, IDOR’s hepatology adapted to the immediate public health urgency worldwide, shifting its focus to better understand the new disease. Dr. Renata Perez, for example, conducted studies about the impact of liver enzyme alterations and steatosis on disease progression.
Dr. Ana Pittella, mentioned many times in the hepatology research initiatives, has also contributed to COVID-19 studies. She served as the principal investigator for the Oxford University/AstraZeneca vaccine trials in Rio de Janeiro, one of the first vaccines made available to the public. She highlights, “The study will be completed later this year, and it was a significant challenge and a tremendous source of pride to be part of this effort alongside IDOR.”
In addition to playing a crucial role in vaccine research, Dr. Pittella is one of the key leaders in the field of hepatology at IDOR. As the coordinator of the inpatient unit and the Medical Clinic Service at Quinta D’Or Hospital, she has direct contact with the clinical, surgical, and onco-hematologic centers of the hospital, contributing to patient recruitment for severalresearch projects.
Apart from being one of the founders and active researchers in D’Or Hepatology, presenting until this day its scientific sessions alongside Dr. Paraná, she also has a direct connection to IDOR’s education initiatives. This was, in fact, her first involvement with the Institute, and she continues to serve as a mentor to medical residents at Quinta D’Or. She is also excited about the prospect of guiding the new residency program in hepatology, which is still in evaluation. “We currently have four R2 medical residents, and three R1 residents, and we are in the process of obtaining approval for the hepatology residency!”, she states.
As one of the fastest-growing fields at IDOR in recent years, hepatology research stands out due to its skilled leadership, its proximity to Rede D’Or’s clinical care, its strong connection to education, and, most importantly, its commitment to advancing the scientific understanding of liver diseases and disseminating this information to the specialized public, contributing to the improvement of clinical practices in the country.
Written by Maria Eduarda Ledo de Abreu.