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221 Natural history of chronic liver disease (CLD) in the dionysos cohort by ten years of follow-up
Category 2b lactitol 60g/day, rifaximine 1200mg/day and no treatment. The main endpoint of the study was the occurrence of overt HE during the first month after TIPS. Seventy-five consecutive cirrhotics (49M, age 57±11, ChildPugh-class 20A-42B-13C, alcoholic etiology: 25pts) submitted to TIPS for variceal bleeding (50pts) or refractory ascites (25pts) were enrolled. Immediately after TIPS the patients were randomized to receive one of the above treatments. Patients were evaluated before TIPS and 7/14/21/30 days after TIPS by examining and grading mental status, asterixis, plasma ammonia and trail making test (TMT-A). The 3 groups were comparable for age, sex, etiology, Child-Pugh-score, post-TIPS porto-hepatic gradient (HVPG) and previous episodes of HE. Twenty-five patients developed HE in the study period (33.3%): 9 in the lactitol, 8 in the rifaximine and 8 in the no-treatment group. The incidence of HE was similar in the three groups (log rank test; p=0.97). Five patients died during the first month following TIPS. Variables that achieved statistical significance as predictors of post-TIPS HE by multivariate analysis were: previous episode of HE, basal TMT-A Z-score >1.5 and HVPG after TIPS <8mmHg. Our data show that treatment with lactitol or rifaximin does not prevent HE during the first month after TIPS.
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Methods: In a prospective evaluation 13 patients with complicated LCI (Cgroup: 53.4 (37.6–66.2) years) were treated with (ePTFE)-covered TIPSS (2416 e , Gore-Viatorr, W.L. Gore, USA). A control group matched in age and Child score (UC-group: 57.9 (37.5–66.8) years), received a conventional uncovered TIPSS (384 e , Memotherm, Angiomed, FRG). All patients underwent venous portography for TIPSS patency at 6 and 12 months and when indicated further intervention. Results: The number of reinterventions and additional stents were significantly lower in the C-group (6 months: 2 vs. 13; 12 month: 0 vs. 6, p< 0.01), resulting in significantly lower procedure-related cost at 6 and 12 months (215 (215-829) e vs. 599 (215-1596) e and 215 vs. 384 (215-767) e (p< 0.001). Conclusion: The benefit of covered stents with a lower reintervention rate is obvious, but the saving of cost for angiographic procedures in the follow-up period of 12 months did not outweigh the initial higher stent cost in patients with covered TIPSS. The cost effectiveness may be improved, when surveillance angiography is not necessary with covered TIPSS.
223 REVERSIBILITY OF CIRRHOSIS IS ASSOCIATED WITH A DECREASE OF LIVER-RELATED COMPLICATIONS
221 NATURAL HISTORY OF CHRONIC LIVER DISEASE (CLD) IN THE DIONYSOS COHORT BY TEN YEARS OF FOLLOW UP
L. Miglioli 1 , F. Masutti 2 , L. Croce 2 , G. Bedogni 1 , A. Castiglione 2 , L. Visintin 2 , C. Campello 3 , G. Dal Molin 3 , C. Tiribelli 2 , S. Bellentani 1 . 1 Liver and Nutrition Center, Fondo Studi Fegato, Modena, Italy; 2 Liver Center, Fondo Studi Fegato, Trieste, Italy; 3 IRCCS Burlo Garofolo, Trieste, Italy Aims: To design natural history of CLD, and incidence of HBV and HCV infection in the Dionysos cohort over 10 years. Methods: 64% of the 6917 subjects enrolled in 1991-92 were screened again, and overall annual mortality rate (MR) was recorded. Results: Incidence of HBV and HCV infections was low (3/100,000 of new cases per year of both HbsAg-HBVDNA positive, and HCVRNA positive). MR in the cirrhotic population was almost 10× higher than MR in the non-cirrhotic population (2.6% vs. 0.28 % per year, p<0.0001). Within cirrhosis, 50% of the patients with alcoholic cirrhosis died in 10 years vs. 32% of HCV-induced cirrhosis; none of the patients with HBV-induced cirrhosis died. The incidence rate of HCC on cirrhosis was 2.1% per year. Among the 83 HbsAg-HBVDNA positive subjects in 1991, 7.2% cleared HBVDNA; diagnosis remained mostly unchanged: 52% still apparently inactive carriers, 19% show fatty liver at ultrasounds, 23% have chronic hepatitis (CH), and 6% cirrhosis (biopsy proven). Among the 162 antiHCVHCVRNA positive in 1991, 44% were asymptomatic with normal ALT, 41% had CH and 15% had cirrhosis; 7.5% of the patients with CH evolved in cirrhosis (annual rate of 0.75%), and 17% of the inactive HCV carriers developed CH (annual rate of 1.7%). Conclusions: In an open population of Northern Italy: MR is significantly higher among cirrhotic than non-cirrhotic subjects, with alcohol abuse killing more than HCV; incidence of both HBV and HCV infections is extremely low; HCV infection is more rapidly progressive than HBV infection.
J. Serpaggi 1 , P. Lebray 1 , B. Nalpas 1 , A. Vallet-Pichard 1 , E. Morales 1 , N. Youssef 2 , F. Carnot 3 , H. Fontaine 1 , P. Bedossa 4 , S. Pol 1 . 1 Liver Unit and INSERM U-370, 2 Dept. of Pathology, Necker-Enfants-Malades Hospital, Paris; 3 Dept. of Pathology, Georges Pompidou Hospital, Paris; 4 Dept. of Pathology, Kremlin Bicêtre Hospital, Paris, France Aim: To assess the impact of cirrhosis reversibility on survival and occurrence of cirrhosis complications. Methods: Retrospective analysis of patients with biopsy-proven cirrhosis and post-treatment biopsy (january 1980 - may 2003). Cirrhosis reversibility was defined as a decrease of the Metavir fibrosis score≥ 2 after two independent blinded analysis. Cirrhosis-related complications included variceal bleeding, ascitis, spontaneous bacterial peritonitis, hepatocellular carcinoma and hepatic encephalopathy. Results: Twenty-two (14/101 HCV-, 3/16 HBV-, 5/10 autoimmune- and 0/9 alcool-related, all Child-Pugh A) of the 136 cirrhotic patients (16.17%) showed reversibility of cirrhosis. The mean decrease of activity scores by METAVIR was 1.35 ± 1.04 for patients with and 0.50 ± 1.06 for patients without reversibility (p< 0.005). Among the 17 patients with regressive viral cirrhosis, 15 were sustained virologic responders (37.7% of the total of complete responders) and 2 biochemical responders. After a mean follow-up of 7 ± 3 years, there were significantly less cirrhosis-related complications (0% vs 25.4%, p= 0.004) and a decrease in mortality (0% vs 17.5%, p= 0.04) in patients with reversibility. Among responders to treatment, liver-related complications were less frequent in patients with than without reversibility: 0% vs 21.1% (p= 0.04). Conclusions: Complete regression of cirrhosis may be associated with a suppression of the necro-inflammation and result in a disappearance of liver-related morbidity and mortality, improving survival. In the absence of cirrhosis reversibility, a close monitoring should be maintained since sustained response does not exclude the risk of complication.
224 ASSOCIATION OF A SELECTIVE ENDOTHELIN-A RECEPTOR 222 COST ANALYSIS OF E-PTFE COVERED TIPS STENTS COMPARED TO BARE STENTS
J. Ockenga 1 , T. Ockenga 1 , T. Kroencke 2 , M. Plauth 1 , E. Kasim 1 , J. Petersein 2 , H. Schmidt 1 , H. Lochs 1 . 1 Gastroenterology, Hepatology and Endocrinology, Berlin, Germany; 2 Radiology, Berlin, Germany Background: The use of expanded-polytetrafluoroethylene (ePTFE)covered TIPS stents results in an improved primary patency rate but the stents are more expensive. The aim of the study was to evaluate if a reduction in the follow-up cost for angiographic interventions justify the initial higher cost for covered TIPSS.
ANTAGONIST (ET-A RA) COULD IMPROVE THE OUTCOME OF PATIENTS WITH HEPATORENAL SYNDROME (HRS)
A. Popescu, M. Voiculescu. Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania HRS involves an impairment on hepatic and renal hemodynamics. Several studies have found 2 to 5- fold increases in plasma concentration of ET-1 in cirrhosis, with maximal elevations in HRS; ET-A RA could counteract renal vasoconstriction, sodium retention, kidney fibrosis. Aim: To evaluate the potential benefit of an ET-RA (LU-135252) associated to terlipressin in the treatment of HRS.
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Methods: In a prospective evaluation 13 patients with complicated LCI (Cgroup: 53.4 (37.6–66.2) years) were treated with (ePTFE)-covered TIPSS (2416 e , Gore-Viatorr, W.L. Gore, USA). A control group matched in age and Child score (UC-group: 57.9 (37.5–66.8) years), received a conventional uncovered TIPSS (384 e , Memotherm, Angiomed, FRG). All patients underwent venous portography for TIPSS patency at 6 and 12 months and when indicated further intervention. Results: The number of reinterventions and additional stents were significantly lower in the C-group (6 months: 2 vs. 13; 12 month: 0 vs. 6, p< 0.01), resulting in significantly lower procedure-related cost at 6 and 12 months (215 (215-829) e vs. 599 (215-1596) e and 215 vs. 384 (215-767) e (p< 0.001). Conclusion: The benefit of covered stents with a lower reintervention rate is obvious, but the saving of cost for angiographic procedures in the follow-up period of 12 months did not outweigh the initial higher stent cost in patients with covered TIPSS. The cost effectiveness may be improved, when surveillance angiography is not necessary with covered TIPSS.
223 REVERSIBILITY OF CIRRHOSIS IS ASSOCIATED WITH A DECREASE OF LIVER-RELATED COMPLICATIONS
221 NATURAL HISTORY OF CHRONIC LIVER DISEASE (CLD) IN THE DIONYSOS COHORT BY TEN YEARS OF FOLLOW UP
L. Miglioli 1 , F. Masutti 2 , L. Croce 2 , G. Bedogni 1 , A. Castiglione 2 , L. Visintin 2 , C. Campello 3 , G. Dal Molin 3 , C. Tiribelli 2 , S. Bellentani 1 . 1 Liver and Nutrition Center, Fondo Studi Fegato, Modena, Italy; 2 Liver Center, Fondo Studi Fegato, Trieste, Italy; 3 IRCCS Burlo Garofolo, Trieste, Italy Aims: To design natural history of CLD, and incidence of HBV and HCV infection in the Dionysos cohort over 10 years. Methods: 64% of the 6917 subjects enrolled in 1991-92 were screened again, and overall annual mortality rate (MR) was recorded. Results: Incidence of HBV and HCV infections was low (3/100,000 of new cases per year of both HbsAg-HBVDNA positive, and HCVRNA positive). MR in the cirrhotic population was almost 10× higher than MR in the non-cirrhotic population (2.6% vs. 0.28 % per year, p<0.0001). Within cirrhosis, 50% of the patients with alcoholic cirrhosis died in 10 years vs. 32% of HCV-induced cirrhosis; none of the patients with HBV-induced cirrhosis died. The incidence rate of HCC on cirrhosis was 2.1% per year. Among the 83 HbsAg-HBVDNA positive subjects in 1991, 7.2% cleared HBVDNA; diagnosis remained mostly unchanged: 52% still apparently inactive carriers, 19% show fatty liver at ultrasounds, 23% have chronic hepatitis (CH), and 6% cirrhosis (biopsy proven). Among the 162 antiHCVHCVRNA positive in 1991, 44% were asymptomatic with normal ALT, 41% had CH and 15% had cirrhosis; 7.5% of the patients with CH evolved in cirrhosis (annual rate of 0.75%), and 17% of the inactive HCV carriers developed CH (annual rate of 1.7%). Conclusions: In an open population of Northern Italy: MR is significantly higher among cirrhotic than non-cirrhotic subjects, with alcohol abuse killing more than HCV; incidence of both HBV and HCV infections is extremely low; HCV infection is more rapidly progressive than HBV infection.
J. Serpaggi 1 , P. Lebray 1 , B. Nalpas 1 , A. Vallet-Pichard 1 , E. Morales 1 , N. Youssef 2 , F. Carnot 3 , H. Fontaine 1 , P. Bedossa 4 , S. Pol 1 . 1 Liver Unit and INSERM U-370, 2 Dept. of Pathology, Necker-Enfants-Malades Hospital, Paris; 3 Dept. of Pathology, Georges Pompidou Hospital, Paris; 4 Dept. of Pathology, Kremlin Bicêtre Hospital, Paris, France Aim: To assess the impact of cirrhosis reversibility on survival and occurrence of cirrhosis complications. Methods: Retrospective analysis of patients with biopsy-proven cirrhosis and post-treatment biopsy (january 1980 - may 2003). Cirrhosis reversibility was defined as a decrease of the Metavir fibrosis score≥ 2 after two independent blinded analysis. Cirrhosis-related complications included variceal bleeding, ascitis, spontaneous bacterial peritonitis, hepatocellular carcinoma and hepatic encephalopathy. Results: Twenty-two (14/101 HCV-, 3/16 HBV-, 5/10 autoimmune- and 0/9 alcool-related, all Child-Pugh A) of the 136 cirrhotic patients (16.17%) showed reversibility of cirrhosis. The mean decrease of activity scores by METAVIR was 1.35 ± 1.04 for patients with and 0.50 ± 1.06 for patients without reversibility (p< 0.005). Among the 17 patients with regressive viral cirrhosis, 15 were sustained virologic responders (37.7% of the total of complete responders) and 2 biochemical responders. After a mean follow-up of 7 ± 3 years, there were significantly less cirrhosis-related complications (0% vs 25.4%, p= 0.004) and a decrease in mortality (0% vs 17.5%, p= 0.04) in patients with reversibility. Among responders to treatment, liver-related complications were less frequent in patients with than without reversibility: 0% vs 21.1% (p= 0.04). Conclusions: Complete regression of cirrhosis may be associated with a suppression of the necro-inflammation and result in a disappearance of liver-related morbidity and mortality, improving survival. In the absence of cirrhosis reversibility, a close monitoring should be maintained since sustained response does not exclude the risk of complication.
224 ASSOCIATION OF A SELECTIVE ENDOTHELIN-A RECEPTOR 222 COST ANALYSIS OF E-PTFE COVERED TIPS STENTS COMPARED TO BARE STENTS
J. Ockenga 1 , T. Ockenga 1 , T. Kroencke 2 , M. Plauth 1 , E. Kasim 1 , J. Petersein 2 , H. Schmidt 1 , H. Lochs 1 . 1 Gastroenterology, Hepatology and Endocrinology, Berlin, Germany; 2 Radiology, Berlin, Germany Background: The use of expanded-polytetrafluoroethylene (ePTFE)covered TIPS stents results in an improved primary patency rate but the stents are more expensive. The aim of the study was to evaluate if a reduction in the follow-up cost for angiographic interventions justify the initial higher cost for covered TIPSS.
ANTAGONIST (ET-A RA) COULD IMPROVE THE OUTCOME OF PATIENTS WITH HEPATORENAL SYNDROME (HRS)
A. Popescu, M. Voiculescu. Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania HRS involves an impairment on hepatic and renal hemodynamics. Several studies have found 2 to 5- fold increases in plasma concentration of ET-1 in cirrhosis, with maximal elevations in HRS; ET-A RA could counteract renal vasoconstriction, sodium retention, kidney fibrosis. Aim: To evaluate the potential benefit of an ET-RA (LU-135252) associated to terlipressin in the treatment of HRS.