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H E PAT O L O G Y I N F O C U S
GASTROENTEROLOGY & ENDOSCOPY NEWS • FEBRUARY 2015
Experts Picks From the 2014 Liver Meeting Compiled and edited by Adam Marcus
The 2014 Liver Meeting of the American Association for the Study of Liver Diseases (AASLD)was largely a coming-out party for new data on the effectiveness of direct-acting antiviral agents for hepatitis C infection. But not entirely: Researchers presented data from important studies involving other liver ailments, from alcoholic hepatitis to hepatitis B. Gastroenterology & Endoscopy News asked two experts to discuss the abstracts from the meeting they found most compelling. Dr. Liangpunsakul: Suthat Liangpunsakul, MD Associate Professor of Medicine, Biochemistry and Molecular Biology in the Division of Gastroenterology and Hepatology at Indiana University, in Indianapolis
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Combinative Use of Baseline and Dynamic Models in Patients With Severe Alcoholic Hepatitis: Prediction of Death as a Continuum in Risks of Mortality Predicting the prognosis of patients with severe alcoholic hepatitis (AH) typically involves the single use of baseline or dynamic models. Combining the two approaches may allow clinicians to assess outcomes as a continuum in probabilities of death. The researchers used data from patients with severe AH (Maddrey Discriminant Function [mDF] ≥32) treated with steroids to combine baseline (mDF or Model for End-Stage Liver Disease [MELD] score) and on-treatment (Lille score) models. The study included 897 patients, with an average age of 50.6 years (Table). The majority (58.5%) were men; six-month survival was 64.1%. Lille score and six-month survival had a linear relationship, but the association was nonlinear between mDF and survival, with a threshold at an mDF of 90. Using a Cox regression mode, the researchers assessed the likelihood of survival using mDF at day 0 and Lille model at day 7. A patient admitted with an mDF of 100 with a Lille model of 0.25 at day 7 has a 73% chance of being alive after six months. That figure drops to 27.7% if Lille model is 0.7, according to the investigators. The joint-effects model was superior to a model based only on Lille (P=0.016). P The joint-effects model also was better than each model individually, according to the researchers (P<0.001). A patient with a MELD score of 28 and a Lille model of 0.25 has a 73% chance of being alive at six months. That figure falls to 30.3% if the Lille model is 0.7. “The present study stratifies the risk for death in AH, based on severity status at admission and evolution upon therapy,” the researchers wrote. “Such approach results in a balanced evaluation instead of giving a yes/no Manichean prediction of death aiming to define a new therapeutic strategy.”
AH is an acute hepatic inflam-mation associated with significant morbidity and mortality. In severe cases, patients have a very poor prognosis, with short-term mortality of approximately 30% to 50%. Several clinical scoring systems—the Child-Turcotte-Pugh score, the mDF, the Lille modell, MELD scores and the Glasgoow alcoholic hepatitis score—have been derived to predict the clinical outcom mes of patients with AH. The MELD scorre, which was calculated using baseline intern national normalized ratio, creatinine and biliru ubin, is useful for predicting the three-month mortality of patients with AH. The Lille model was developed to determine cases that respond to steroid therapy, using the evolution of laboratory tests (from days 0 and 7). It is also useful in predicting survival: Those with Lille scores below 0.16 and above 0.56 had survival rates of 87% and 21%, respectively. This study is novel, as it proposed to use both baseline MELD and Lille to provide the better mortality assessment for patients with AH and perhaps define those who need therapeutic intervention.
Table. Patient Characteristics Bilirubin 156 µmol/L Prothrombin time 20.2 sec Creatinine 8 mg/L mDF 55 MELD 25.2 Lille model 0.34 mDF, Maddrey Discriminant Function; MELD, Model for End-Stage Liver Disease
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Impact of Intensive Enteral Nutrition in Association With Corticosteroids in the Treatment of Severe Alcoholic Hepatitis: A Multicenter Randomized Controlled Trial Severe alcoholic hepatitis (AH) is associated with a high short-term risk for mortality. Although nutritional support is recommended for these patients, they often have trouble consuming the adequate calories and protein. This study assessed the effects of intensive enteral nutrition (EN) plus steroid therapy on six-month survival in patients with severe AH. The randomized controlled trial was conducted in 18 Belgian and two French hospitals. Patients received
either intensive EN through a feeding tube, and methylprednisolone or conventional nutrition and methylprednisolone. EN consisted of Fresubin HP Energy (Fresenius Kabi) based on the following regimen: 1 L per day for patients with body weight less than 60 kg; 1.5 L per day for body weight 60 to 90 kg; and 2 L per day for body weight above 90 kg. The study included 136 patients with a severe biopsyproven AH (68 per group). Mean daily calorie intake was 2,206±754 versus 1,754±656 for the EN and conventional groups, respectively (P=0.001); P mean daily protein intake was 106±37 versus 80±32 g, respectively (P<0.001). Most patients in the EN group (63.2%) received at least 80% of the planned calorie intake. In an intention-to-treat (ITT) analysis, six-month survival was similar for patients in the EN and convenP=0.316). In a per-protocol tional groups (55.9 vs. 47%; P analysis, six-month survival was higher in the enteral feeding group: 69.8% versus 46.8% (P=0.015). P Mean calorie intake also was associated with a higher sixmonth survival (P=0.002). P
Dr. Liangpunsakul: Patients with P h AH invariably bl experience some d degree of malnutrition. The severity of this protein–calorie malnutrition has been shown to closely correlate with mortality rate. A previous randomized controlled trial (Hepatologyy 2000;32:36-42) compared the therapeutic efficacies of corticosteroid therapy (40 mg/day) versus EN (2,000 kcal/day) and assessed outcomes at 28 days (the end of therapy) and one year later, or until death. The two therapies produced similar initial outcomes; however, patients who received EN developed fewer long-term infections. see Liver Meeting, page 12