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Clinical Significance of Serum Procalcitonin Levels in Patients with Alcoholic Hepatitis
ALCOHOLIC LIVER DISEASE
were more number of coping strategies, principally adaptive ones. Corresponding author: . E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.028
A VALIDATION OF PROGNOSTIC SCORES TO PREDICT MORTALITY IN ALCOHOLIC HEPATITIS Nikhil Suraj, Chethan Govindraju, Prasanth Thayyil Sudheendran, Suthanu A.B. Ponni Krishnan, Kattoor Ramakrishnan Vinayakumar, Premaletha Narayanan Government Medical College Trivandrum, Trivandrum, India
ALD
Aim: Assessment of mortality risk is an important factor in the clinical management of patients with alcoholic hepatitis. There are a number of scoring systems to assess the prognosis and mortality in alcoholic hepatitis. We aimed to evaluate and validate the predictive performances of the Child–Turcotte– Pugh score (CTP), discriminant function (DF), Glasgow alcoholic hepatitis score (GAHS), the model of end-stage liver disease (MELD), the MELD-Na, and the age, bilirubin, international normalized ratio, and creatinine (ABIC) score in patients admitted with alcoholic hepatitis. Material and Methods: The study was conducted as a retrospective observational study. The clinical and biochemical parameters were used to calculate the scores. We applied the scoring systems to all 240 patients hospitalized and diagnosed to have alcoholic hepatitis. The ability of each score to predict mortality was evaluated using receiver operating characteristics curves, and the area under the receiver operating characteristics curves (AUROCs) was used to compare the scores. Results: The 30-day and 90-day mortalities were 14% and 25%, respectively. All the scores except CTP had similar predictive properties with AUROC = 0.73–0.8 for 30-day mortality and 0.69–0.78 for 90-day mortality. There were no statistically significant differences between the models’ performances (P > 0.9). Conclusions: The DF, GAHS, MELD, MELD-Na and ABIC scores each predicted the 30- and 90-day mortality of our patients with alcoholic hepatitis and to the same degree. CTP score is a poor predictor of both short and long term survival.
CLINICAL SIGNIFICANCE OF SERUM PROCALCITONIN LEVELS IN PATIENTS WITH ALCOHOLIC HEPATITIS Chethan Govindaraju, Prasanth Sudheendran, George Peter, Nikhil Suraj, Arun Iyer, Prremaletha Narayanan, Kattoor Vinayakumar Government Medical College Trivandrum, Trivandrum, India
Background and Aims: Procalcitonin, a propeptide of calcitonin, is an early marker of infection. Sepsis in alcoholic hepatitis carries a very high mortality risk. So early diagnosis of sepsis in alcoholic hepatitis is important for optimal management. There are no data to suggest whether serum procalcitonin is an early marker of sepsis in alcoholic hepatitis. Methods: All patients admitted with alcoholic hepatitis underwent procalcitonin measurement on admission. Patients were classified into two groups. Group I—alcoholic hepatitis with infection; Group II—alcoholic hepatitis without infection. ROC was plotted to obtain cutoff of the procalcitonin to compare between the two groups. Results: The study included a total of 80 patients, group I had 50 patients and group II had 30 patients. All were males (mean age 44, range 33–63 years). Age, biochemical parameters, Child–Turcotte Pugh score (CTP), Discriminant function (DF), MELD and procalcitonin were analysed. On multivariate analysis, DF, serum albumin, prothrombin time, urea, total leucocyte count (TLC) and procalcitonin were statistically significant. Procalcitonin was elevated from
Corresponding author: Nikhil Suraj http://dx.doi.org/10.1016/j.jceh.2015.07.029 S14
Figure 1 Receiver–operating characteristic curve. © 2015, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Table 1 Multivariate Logistic Regression Analysis. Variables
Unstandardised coefficients B
DF
T
Standardised coefficients Std. Error
P
Beta
CTP
.006 .012
.003 .020
.304 .048
2.131 .037 .600 .551
TLC
.036
.012
.282
3.073 .003
Albumin
.129
.056
.169
2.293 .025
PT/INR
.035
.012
.433
3.007 .004
Urea
.006
.002
.151
2.377 .020
Procalcitonin
.958
.168
.547
5.706 .000
usual baseline cutoff in both the groups. But, procalcitonin was significantly elevated in group I compared to group II, which was statistically significant. Receiver–operating characteristic curve (ROC) was plotted. Area under curve (AUC) was 0.94 (95% CI 0.89–1.003). A cutoff of 0.54 mg/L was obtained to distinguish between the two groups. Conclusions: Serum procalcitonin is a very useful marker to diagnose infection in patients with alcoholic hepatitis. Procalcitonin >0.54 mg/L implies presence of sepsis.
analyses were done using DF as the independent factor. The ability of serum ferritin to predict the severity of AH was evaluated using receiver–operating characteristics (ROC) curve to find area under curve (AUC) and to derive a cut-off level. Results: The study included 160 patients (100% males mean age 44.7 years) with 24 patients in Group I and 136 patients in Group II. Univariate analysis showed that age, CTP, CHILD, MELD, Bilirubin, PTINR, Albumin, Sodium, Ferritin and Infection were statistically significant. In multivariate analysis, age, CTP, ferritin, Albumin and infection came out as independent predictors. We plotted ROC curve taking serum ferritin level and DF and got AUC 0.917 {95% CI (0.87–0.966)} with P = 0.000. A ferritin cut-off level of 212.0 or above (sensitivity 82.6%; specificity 84.3%) clearly showed severe AH. However, we
ALD
Corresponding author: Chethan Govindaraju. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.030
IS SERUM FERRITIN A PREDICTOR OF THE SEVERITY OF ALCOHOLIC HEPATITIS Prasanth Sudheendran, Chethan Govindaraju, George Peter, Nikhil Suraj, Arun Iyer, Premaletha Narayanan, Kattoor Vinayakumar
Figure 1 Receiver–operating characteristic curve.
Government Medical College Trivandrum, Trivandrum, India
Background and Aims: Heavy alcohol consumption is associated with iron overload and elevated serum ferritin levels, and leads to liver injury and alcoholic liver disease. The severity of alcoholic hepatitis (AH) is measured using discriminant function (DF < 32 or DF > 32). But very few studies attempted to correlate the serum ferritin level and severity of AH. Hence, we tried to find out whether serum ferritin correlated with severity of AH and also tried to find a cut-off value to diagnose severe AH. Methods: All patients admitted with AH over an 18month period (cross-sectional study) were divided into two groups depending on DF <32 (GROUP I) and DF >32 (GROUP II). Univariate and multivariate
Table 1 Multivariate Logistic Regression Analysis. Variables
Age
Unstandardised coefficients
Standardised coefficients
B
Beta
Std. Error
T
P
CTP
.010 .100
.003 .016
.189 .550
3.345 6.079
.001 .000
MELD
.003
.007
.039
.373
.709
Albumin
.131‘
.036
.233
3.631
.000
PTINR
.018
.040
.035
.444
.657
Ferritin
.000
.000
.408
5.526
.000
Infections
.209
.042
.291
5.014
.000
Journal of Clinical and Experimental Hepatology | June/July 2015 | Vol. 5 | No. S2 | S13–S20
S15
were more number of coping strategies, principally adaptive ones. Corresponding author: . E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.028
A VALIDATION OF PROGNOSTIC SCORES TO PREDICT MORTALITY IN ALCOHOLIC HEPATITIS Nikhil Suraj, Chethan Govindraju, Prasanth Thayyil Sudheendran, Suthanu A.B. Ponni Krishnan, Kattoor Ramakrishnan Vinayakumar, Premaletha Narayanan Government Medical College Trivandrum, Trivandrum, India
ALD
Aim: Assessment of mortality risk is an important factor in the clinical management of patients with alcoholic hepatitis. There are a number of scoring systems to assess the prognosis and mortality in alcoholic hepatitis. We aimed to evaluate and validate the predictive performances of the Child–Turcotte– Pugh score (CTP), discriminant function (DF), Glasgow alcoholic hepatitis score (GAHS), the model of end-stage liver disease (MELD), the MELD-Na, and the age, bilirubin, international normalized ratio, and creatinine (ABIC) score in patients admitted with alcoholic hepatitis. Material and Methods: The study was conducted as a retrospective observational study. The clinical and biochemical parameters were used to calculate the scores. We applied the scoring systems to all 240 patients hospitalized and diagnosed to have alcoholic hepatitis. The ability of each score to predict mortality was evaluated using receiver operating characteristics curves, and the area under the receiver operating characteristics curves (AUROCs) was used to compare the scores. Results: The 30-day and 90-day mortalities were 14% and 25%, respectively. All the scores except CTP had similar predictive properties with AUROC = 0.73–0.8 for 30-day mortality and 0.69–0.78 for 90-day mortality. There were no statistically significant differences between the models’ performances (P > 0.9). Conclusions: The DF, GAHS, MELD, MELD-Na and ABIC scores each predicted the 30- and 90-day mortality of our patients with alcoholic hepatitis and to the same degree. CTP score is a poor predictor of both short and long term survival.
CLINICAL SIGNIFICANCE OF SERUM PROCALCITONIN LEVELS IN PATIENTS WITH ALCOHOLIC HEPATITIS Chethan Govindaraju, Prasanth Sudheendran, George Peter, Nikhil Suraj, Arun Iyer, Prremaletha Narayanan, Kattoor Vinayakumar Government Medical College Trivandrum, Trivandrum, India
Background and Aims: Procalcitonin, a propeptide of calcitonin, is an early marker of infection. Sepsis in alcoholic hepatitis carries a very high mortality risk. So early diagnosis of sepsis in alcoholic hepatitis is important for optimal management. There are no data to suggest whether serum procalcitonin is an early marker of sepsis in alcoholic hepatitis. Methods: All patients admitted with alcoholic hepatitis underwent procalcitonin measurement on admission. Patients were classified into two groups. Group I—alcoholic hepatitis with infection; Group II—alcoholic hepatitis without infection. ROC was plotted to obtain cutoff of the procalcitonin to compare between the two groups. Results: The study included a total of 80 patients, group I had 50 patients and group II had 30 patients. All were males (mean age 44, range 33–63 years). Age, biochemical parameters, Child–Turcotte Pugh score (CTP), Discriminant function (DF), MELD and procalcitonin were analysed. On multivariate analysis, DF, serum albumin, prothrombin time, urea, total leucocyte count (TLC) and procalcitonin were statistically significant. Procalcitonin was elevated from
Corresponding author: Nikhil Suraj http://dx.doi.org/10.1016/j.jceh.2015.07.029 S14
Figure 1 Receiver–operating characteristic curve. © 2015, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Table 1 Multivariate Logistic Regression Analysis. Variables
Unstandardised coefficients B
DF
T
Standardised coefficients Std. Error
P
Beta
CTP
.006 .012
.003 .020
.304 .048
2.131 .037 .600 .551
TLC
.036
.012
.282
3.073 .003
Albumin
.129
.056
.169
2.293 .025
PT/INR
.035
.012
.433
3.007 .004
Urea
.006
.002
.151
2.377 .020
Procalcitonin
.958
.168
.547
5.706 .000
usual baseline cutoff in both the groups. But, procalcitonin was significantly elevated in group I compared to group II, which was statistically significant. Receiver–operating characteristic curve (ROC) was plotted. Area under curve (AUC) was 0.94 (95% CI 0.89–1.003). A cutoff of 0.54 mg/L was obtained to distinguish between the two groups. Conclusions: Serum procalcitonin is a very useful marker to diagnose infection in patients with alcoholic hepatitis. Procalcitonin >0.54 mg/L implies presence of sepsis.
analyses were done using DF as the independent factor. The ability of serum ferritin to predict the severity of AH was evaluated using receiver–operating characteristics (ROC) curve to find area under curve (AUC) and to derive a cut-off level. Results: The study included 160 patients (100% males mean age 44.7 years) with 24 patients in Group I and 136 patients in Group II. Univariate analysis showed that age, CTP, CHILD, MELD, Bilirubin, PTINR, Albumin, Sodium, Ferritin and Infection were statistically significant. In multivariate analysis, age, CTP, ferritin, Albumin and infection came out as independent predictors. We plotted ROC curve taking serum ferritin level and DF and got AUC 0.917 {95% CI (0.87–0.966)} with P = 0.000. A ferritin cut-off level of 212.0 or above (sensitivity 82.6%; specificity 84.3%) clearly showed severe AH. However, we
ALD
Corresponding author: Chethan Govindaraju. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2015.07.030
IS SERUM FERRITIN A PREDICTOR OF THE SEVERITY OF ALCOHOLIC HEPATITIS Prasanth Sudheendran, Chethan Govindaraju, George Peter, Nikhil Suraj, Arun Iyer, Premaletha Narayanan, Kattoor Vinayakumar
Figure 1 Receiver–operating characteristic curve.
Government Medical College Trivandrum, Trivandrum, India
Background and Aims: Heavy alcohol consumption is associated with iron overload and elevated serum ferritin levels, and leads to liver injury and alcoholic liver disease. The severity of alcoholic hepatitis (AH) is measured using discriminant function (DF < 32 or DF > 32). But very few studies attempted to correlate the serum ferritin level and severity of AH. Hence, we tried to find out whether serum ferritin correlated with severity of AH and also tried to find a cut-off value to diagnose severe AH. Methods: All patients admitted with AH over an 18month period (cross-sectional study) were divided into two groups depending on DF <32 (GROUP I) and DF >32 (GROUP II). Univariate and multivariate
Table 1 Multivariate Logistic Regression Analysis. Variables
Age
Unstandardised coefficients
Standardised coefficients
B
Beta
Std. Error
T
P
CTP
.010 .100
.003 .016
.189 .550
3.345 6.079
.001 .000
MELD
.003
.007
.039
.373
.709
Albumin
.131‘
.036
.233
3.631
.000
PTINR
.018
.040
.035
.444
.657
Ferritin
.000
.000
.408
5.526
.000
Infections
.209
.042
.291
5.014
.000
Journal of Clinical and Experimental Hepatology | June/July 2015 | Vol. 5 | No. S2 | S13–S20
S15