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946 PREDICTION OF MORTALITY IN PATIENTS WITH ALCOHOLIC HEPATITIS: COMPARISON OF PROGNOSTIC SCORES
S354
POSTERS
945 HISTOLOGICAL DEFINITIONS OF NON-ALCOHOLIC STEATOHEPATITIS IN A COHORT OF MORBIDLY OBESE PATIENTS SUBMITTED TO BARIATRIC SURGERY: COMPARISON OF TWO CLASSIFICATIONS AND METABOLIC CORRELATES M.V. Machado1 , A. Costa2 , J. Coutinho3 , F. Carepa3 , N. Alves3 , H. Cortez-Pinto1,4 . 1 Departamento de Gastrenterologia e Hepatologia, 2 Departamento de Anatomia Patol´ ogica, 3 Departamento de Cirurgia, Hospital de Santa Maria, Lisboa, Portugal, 4 Unidade de Nutri¸ca˜ o e Metabolismo, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal E-mail: [email protected] Background and Aims: Histological definition of non-alcoholic steatohepatitis (NASH), in morbidly obese patients, is controversial, being the most accepted classifications the one proposed by Matteoni et al. (MC) and the NAFLD Activity Score (NAS). We aimed to compare both classifications, analyzing factors related to NASH. Methods: Morbidly obese patients submitted to bariatric surgery were consecutively and prospectively recruited. Other causes of liver disease and alcohol intake >20 g/day were excluded. Surgical liver biopsies were evaluated using Matteoni et al. (MC) and the NAFLD Activity Score (NAS). Results: 40 patients, 3 men; age: 42±12 years; body mass index (BMI): 47±9 kg/m2 . Steatosis (>5%), was present in 95%; fibrosis in 97.5%, severe in 10%, one patient presenting with unexpected hepatic cirrhosis. With MC, NASH was diagnosed in 4 patients, simple steatosis in 18 patients, and 16 patients were classified in the controversial group 2 (steatosis plus inflammation without criteria of NASH). With NAS, definitive diagnosis of NASH was made in 8 patients, exclusion of NASH in 21 patients, 11 remaining unclassified. Inter-rater agreement between both classifications, when categorized in 3 subgroups, definitive NASH (NAS 5/MC 3 and 4), unclassified (NAS 3−4/MC 2) and exclusion of NASH (NAS < 3/MC 1), was 0.77 (p = 0.123). Group 2 of MC occurred in all subgroups of NAS. NASH diagnosed by either MC or NAS associated to increases in aminotransferases levels, hypertriglyceridaemia, a higher HOMA and a greater number of metabolic syndrome features (p < 0.05). All patients with NASH (MC or NAS) had evidence of insulin resistance (HOMA 3) and criteria for metabolic syndrome (3 features) (p < 0.05). Both classifications associated to steatosis severity, but only MC NASH with fibrosis severity. Conclusion: MC and NAS classifications presented only a moderate agreement in respect to the diagnosis of NASH. Using NAS score, NASH was two fold more frequent than if MC was applied. MC correlated better to the severity of hepatic fibrosis, the main factor associated to more advanced disease, however a more significant percentage of patients are left on a rather undefined group of NAFLD. Applying either classification, NASH associated strongly with metabolic disturbances, in morbidly obese. 946 PREDICTION OF MORTALITY IN PATIENTS WITH ALCOHOLIC HEPATITIS: COMPARISON OF PROGNOSTIC SCORES M.V. Machado, J. Nunes, H. Cortez-Pinto, F. Ramalho, E. Monteiro. Departamento de Gastroenterologia E Hepatologia, Hospital de Santa Maria, Lisbon, Poland E-mail: [email protected] Background: Severity stratification in patients with alcoholic hepatitis (AH), allow us to predict mortality risk and to guide our clinical management. Although there are several prognostic models, information is lacking concerning the comparison of their prognostic value. Aims: 1) To evaluate mortality, its causes, and related risk factors in patients with AH. 2) To compare Child-Pugh-Turcotte (CPT), modified
Maddrey Index (MI), MELD and Glasgow Alcoholic Hepatitis Score (GASH), as mortality predictors. Methods: From 2002 to 2006 all patients admitted with AH, in a Hepatology Department were evaluated and followed up to 6 months. CPT, MI, MELD and GASH were calculated and the respective scores were analyzed using ROC curves, and compared with Clarke-Pearson method. Results: 76 patients were admitted, 60 men, with a mean age of 50±10 years, hepatic cirrhosis (liver biopsy or clinical evidence of portal hypertension) in 82%. The present episode was the first hepatic decompensation in 71%. 47 patients had severe AH, with a MI32, 9 were treated with corticosteroids and 36 with pentoxifilin. One month mortality was 14.5%, and at 6 months mortality was 26.3%, being infection the main cause of death (90%) followed by renal failure (RF) in 5% and gastrointestinal bleeding in 5%. One month mortality associated with RF, coagulation impairment and lactic dehydrogenase levels (multivariate analysis). AUROC to assess mortality were: GASH9 = 0.732, MELD20 = 0.731, CPT12 = 0.692 and MI32 = 0.670; no statistical differences between indices. Percentage of patients correctly classified was: GASH 67.1%, MELD 60.5%, MI 50% and CPT 47.4%. Six months mortality associated to infection, RF and coagulation impairment (multivariate analysis). AUROC: GASH9 = 0.723, MELD20 = 0.695, MI32 = 0.691 and CPT12 = 0.689; no statistical differences between indices. Percentage of patients correctly classified was: GASH 71.0%, MELD 64.5%, MI 59.2% and CPT 56.6%. Conclusion: AH presentation was the first manifestation of hepatic disease in the majority of patients, with a high mortality (26% at 6 months). Infection was the main cause of death. Comparing several risk stratification scores available, all scores performed equally, with a moderate prognostic acuity.
947 FEASIBILITY AND PERFORMANCE OF THE LIVER STIFFNESS (LSM) MEASUREMENT FOR THE DIAGNOSIS OF FIBROSIS IN NAFLD A. Mahmoudi1 , G. Nkontchou1 , M. Lemoine1 , J. Reboul Marty2 , N. Ganne Carrie1 , V. Grando Lemaire1 , J.C. Trinchet1 , M. Beaugrand1 . 1 Liver Unit, 2 Public Health, Hˆ opital Jean Verdier, Assistance PubliqueHˆopitaux de Paris, UPRES EA 3409, UFR SMBH, Universit´e Paris, Bondy, France E-mail: [email protected] LMS has been validated as a non invasive tool for the evaluation of liver diseases But information’s are still limited concerning it’s feasibility and performances in patients with NAFLD and the possible influence of inflammation and or steatosis on the results. This study was aimed at assessing these different points. Patients and Methods: We studied 137 patients (74 male, mean age: 55±12 yrs) referred for liver biopsy and presenting with the metabolic syndrome and liver enzyme abnormalities. Alcohol consumption >20 g/day, HCV or HBV infection or others causes of liver diseases were excluded in all cases. LSM by Fibroscan (Echosens Paris) was performed by experienced operator not aware of any biological or histological results. The measure was considered valid if 8 acquisitions were recorded by the success to rate >50%. All liver biopsies were coded according to the Brunt classification staging taking in account fibrosis (F0−F4), Activity (A0-A4), steatosis (S1-S3). Results: LSM failed in 45 patients (32%). The rate of failure was closely related to obesity. Among the 92 remaining patients, all had NAFLD or NASH with the following fibrosis score: F0 = 4, F1 = 27, F2 = 28, F3 = 27 and F4 = 10. The main values LSM (95% CI) were respectively F0: 5.37 kPa (3.66−7.09), F1: 7.21 kPa (6.10−8.32), F2: 10.45 kPa (8.60−12.27); F3: 13.71 kPa (9.72−17.7); F4: 26.77 kPa (22.65−30.88). In univariate analysis the stage of fibrosis (p < 0.0001) and the degree of activity was correlated to LSM. Steatosis was not. In multivariate analysis, only the stage of fibrosis was correlated to LSM F0−F1/F2, F3, F4: 0.77 and for cirrhosis F0−F1−F2−F3/F4: 0.97.
POSTERS
945 HISTOLOGICAL DEFINITIONS OF NON-ALCOHOLIC STEATOHEPATITIS IN A COHORT OF MORBIDLY OBESE PATIENTS SUBMITTED TO BARIATRIC SURGERY: COMPARISON OF TWO CLASSIFICATIONS AND METABOLIC CORRELATES M.V. Machado1 , A. Costa2 , J. Coutinho3 , F. Carepa3 , N. Alves3 , H. Cortez-Pinto1,4 . 1 Departamento de Gastrenterologia e Hepatologia, 2 Departamento de Anatomia Patol´ ogica, 3 Departamento de Cirurgia, Hospital de Santa Maria, Lisboa, Portugal, 4 Unidade de Nutri¸ca˜ o e Metabolismo, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal E-mail: [email protected] Background and Aims: Histological definition of non-alcoholic steatohepatitis (NASH), in morbidly obese patients, is controversial, being the most accepted classifications the one proposed by Matteoni et al. (MC) and the NAFLD Activity Score (NAS). We aimed to compare both classifications, analyzing factors related to NASH. Methods: Morbidly obese patients submitted to bariatric surgery were consecutively and prospectively recruited. Other causes of liver disease and alcohol intake >20 g/day were excluded. Surgical liver biopsies were evaluated using Matteoni et al. (MC) and the NAFLD Activity Score (NAS). Results: 40 patients, 3 men; age: 42±12 years; body mass index (BMI): 47±9 kg/m2 . Steatosis (>5%), was present in 95%; fibrosis in 97.5%, severe in 10%, one patient presenting with unexpected hepatic cirrhosis. With MC, NASH was diagnosed in 4 patients, simple steatosis in 18 patients, and 16 patients were classified in the controversial group 2 (steatosis plus inflammation without criteria of NASH). With NAS, definitive diagnosis of NASH was made in 8 patients, exclusion of NASH in 21 patients, 11 remaining unclassified. Inter-rater agreement between both classifications, when categorized in 3 subgroups, definitive NASH (NAS 5/MC 3 and 4), unclassified (NAS 3−4/MC 2) and exclusion of NASH (NAS < 3/MC 1), was 0.77 (p = 0.123). Group 2 of MC occurred in all subgroups of NAS. NASH diagnosed by either MC or NAS associated to increases in aminotransferases levels, hypertriglyceridaemia, a higher HOMA and a greater number of metabolic syndrome features (p < 0.05). All patients with NASH (MC or NAS) had evidence of insulin resistance (HOMA 3) and criteria for metabolic syndrome (3 features) (p < 0.05). Both classifications associated to steatosis severity, but only MC NASH with fibrosis severity. Conclusion: MC and NAS classifications presented only a moderate agreement in respect to the diagnosis of NASH. Using NAS score, NASH was two fold more frequent than if MC was applied. MC correlated better to the severity of hepatic fibrosis, the main factor associated to more advanced disease, however a more significant percentage of patients are left on a rather undefined group of NAFLD. Applying either classification, NASH associated strongly with metabolic disturbances, in morbidly obese. 946 PREDICTION OF MORTALITY IN PATIENTS WITH ALCOHOLIC HEPATITIS: COMPARISON OF PROGNOSTIC SCORES M.V. Machado, J. Nunes, H. Cortez-Pinto, F. Ramalho, E. Monteiro. Departamento de Gastroenterologia E Hepatologia, Hospital de Santa Maria, Lisbon, Poland E-mail: [email protected] Background: Severity stratification in patients with alcoholic hepatitis (AH), allow us to predict mortality risk and to guide our clinical management. Although there are several prognostic models, information is lacking concerning the comparison of their prognostic value. Aims: 1) To evaluate mortality, its causes, and related risk factors in patients with AH. 2) To compare Child-Pugh-Turcotte (CPT), modified
Maddrey Index (MI), MELD and Glasgow Alcoholic Hepatitis Score (GASH), as mortality predictors. Methods: From 2002 to 2006 all patients admitted with AH, in a Hepatology Department were evaluated and followed up to 6 months. CPT, MI, MELD and GASH were calculated and the respective scores were analyzed using ROC curves, and compared with Clarke-Pearson method. Results: 76 patients were admitted, 60 men, with a mean age of 50±10 years, hepatic cirrhosis (liver biopsy or clinical evidence of portal hypertension) in 82%. The present episode was the first hepatic decompensation in 71%. 47 patients had severe AH, with a MI32, 9 were treated with corticosteroids and 36 with pentoxifilin. One month mortality was 14.5%, and at 6 months mortality was 26.3%, being infection the main cause of death (90%) followed by renal failure (RF) in 5% and gastrointestinal bleeding in 5%. One month mortality associated with RF, coagulation impairment and lactic dehydrogenase levels (multivariate analysis). AUROC to assess mortality were: GASH9 = 0.732, MELD20 = 0.731, CPT12 = 0.692 and MI32 = 0.670; no statistical differences between indices. Percentage of patients correctly classified was: GASH 67.1%, MELD 60.5%, MI 50% and CPT 47.4%. Six months mortality associated to infection, RF and coagulation impairment (multivariate analysis). AUROC: GASH9 = 0.723, MELD20 = 0.695, MI32 = 0.691 and CPT12 = 0.689; no statistical differences between indices. Percentage of patients correctly classified was: GASH 71.0%, MELD 64.5%, MI 59.2% and CPT 56.6%. Conclusion: AH presentation was the first manifestation of hepatic disease in the majority of patients, with a high mortality (26% at 6 months). Infection was the main cause of death. Comparing several risk stratification scores available, all scores performed equally, with a moderate prognostic acuity.
947 FEASIBILITY AND PERFORMANCE OF THE LIVER STIFFNESS (LSM) MEASUREMENT FOR THE DIAGNOSIS OF FIBROSIS IN NAFLD A. Mahmoudi1 , G. Nkontchou1 , M. Lemoine1 , J. Reboul Marty2 , N. Ganne Carrie1 , V. Grando Lemaire1 , J.C. Trinchet1 , M. Beaugrand1 . 1 Liver Unit, 2 Public Health, Hˆ opital Jean Verdier, Assistance PubliqueHˆopitaux de Paris, UPRES EA 3409, UFR SMBH, Universit´e Paris, Bondy, France E-mail: [email protected] LMS has been validated as a non invasive tool for the evaluation of liver diseases But information’s are still limited concerning it’s feasibility and performances in patients with NAFLD and the possible influence of inflammation and or steatosis on the results. This study was aimed at assessing these different points. Patients and Methods: We studied 137 patients (74 male, mean age: 55±12 yrs) referred for liver biopsy and presenting with the metabolic syndrome and liver enzyme abnormalities. Alcohol consumption >20 g/day, HCV or HBV infection or others causes of liver diseases were excluded in all cases. LSM by Fibroscan (Echosens Paris) was performed by experienced operator not aware of any biological or histological results. The measure was considered valid if 8 acquisitions were recorded by the success to rate >50%. All liver biopsies were coded according to the Brunt classification staging taking in account fibrosis (F0−F4), Activity (A0-A4), steatosis (S1-S3). Results: LSM failed in 45 patients (32%). The rate of failure was closely related to obesity. Among the 92 remaining patients, all had NAFLD or NASH with the following fibrosis score: F0 = 4, F1 = 27, F2 = 28, F3 = 27 and F4 = 10. The main values LSM (95% CI) were respectively F0: 5.37 kPa (3.66−7.09), F1: 7.21 kPa (6.10−8.32), F2: 10.45 kPa (8.60−12.27); F3: 13.71 kPa (9.72−17.7); F4: 26.77 kPa (22.65−30.88). In univariate analysis the stage of fibrosis (p < 0.0001) and the degree of activity was correlated to LSM. Steatosis was not. In multivariate analysis, only the stage of fibrosis was correlated to LSM F0−F1/F2, F3, F4: 0.77 and for cirrhosis F0−F1−F2−F3/F4: 0.97.