- Email: [email protected]
Histologic features of steatohepatitis in hepatitis C
penod 7he increase aitected both men and women and all ethnic groups Overall, men ~
MELD t: 1-9 MELD 2:10-19 MELD 3:20-29 MELD 4:30-39 Child A Child B Child C
n ....... 35 62 14 3
deaths 90 d 5 (14%) 11 (18%) 8 (57%) 2 (67%)
30
0
44 33
11 (25%) 14 (42%I
,,deaths l y
9 (26%) 25 (40%) 10 (71%) 3 (100%) 2 (7%) 20 (45%) 23 (70%}
M1414 HVPG Measurements to Guide Secondary Prophylaxis for Variceal Bleeding: A Decision Analysis Daniel L Raines, Andrew W. Dupont, Miguel R. Arguedas Background & Aims: Measurement of hepatic venous pressure gradient (HVPG) can evaluate response to prophylaxis in patients with a prior variceal bleed (VB) However the costelfl:ctiveness of HVPG measurement to guide secondary prophylaxis has not been examined Methods: A decision analysis tree was constructed (DATA 3.5) Total costs, VB episodes and proportion of patients alive were calculated tot the fbllowing stmtegms: 1) B-blockers without hemodynamic monitoring, 2) Combination B-blockers and nitrates without rnonitornil, 3) HVPG measurement 12 weeks after ininatmg B-blockers, 4) HVPG measurement 12 weeks after initiating combination therapy, 5) HVPG measuremem prior to and 12 weeks after mitiatnig B-blockers, 6) HVPG measurement prior to and 12 weeks after niitiatmg combination therapy, and 7) endoscopic variceal ligation (EVL) Hemodynamic response was defined as: HVPG <12mmHg or a decrease ->20% in HVPG (2 measurements) or an HVPG <12mmHg (1 measurement). Non-responders underwent EVL. Probabilities were obtained from the hterature using Medline. All costs represented Medicare reimbursements at our institution. Drag costs represented the average wholesale price. The time horizon was 1 year. Results: The table shows total costs, proportion of patients with VB and proportion alive at 1 year (in order of increasing costs). After eliminating more expensive and less effective strategies, the two remaining were combnianon therapy without monitornig and combination therapy with 2 HVPG measurements. The incremental cost-effectiveness ratio (ICER) per year of life saved of combination therapy with two HVPG measurements compared to combination therapy without monitoring was $2,274,500, whereas the cost per VB prevented was $5,921. Results were sensitive to the tinte horizon with the ICER of hemodynamic monitoring improving as the time horizon extended and to the probability of hemod D namic response and cost of HVPG. Conclusions: At one year, hemodynamic monitoring with HVPG measurements to guide secondary prophylaxis is an expensive strategy in terms of maximizing patient survival Targeting hemod}mamic monitoring to guide secondary prophylaxis in patients in whom overall survival is expected to be prolonged may be an appropriate strategy.
M1412
Percutaneous Liver Biopsy by the U,S. Gastroenterologists: A Vanishing Skill? Muhammad K Hasan~ Dawd S, Stokesberry, Da'~d M ]hompson, Aura Parra, Sikandar A. Meslya Pu~mse: liver biopsy is commonly performed for the assessment of hepatitis C and other chronic Ever diseases Tradnionally, gastroenterologists (GI) and hepatologists have performed liver biopsy utilizing a variety of methods Over t k past decade radiologists, utilizing real time imaging technique have been increasingly requested by practitioners to perform liver biopsy This sin@ investigates factors that nifluence gastroenterologists and hepatologists decision to perform liver biopsy themseb
cost(us$)
Combination B.,blocker EVL Combination (1 HVPG) B,.blocker(1 I,NPG) ComblnWdon(2 HVIR3) B . ~ e r (2 I'NP6)
M1413
3,201 3,868 4,229 5,g83 5,137 7,750 7,938
....
%vB
17,9 24 24 21.1 21,3 17,1 17,2
, %A,wOyur)
81,4 79,8 79.8 80.6 80,5 81,6 81,5
M1415
Predicting Mortality for Inpatients with Cirrhosis: the Utility of Child@ugh and MELD scores
Histologic Features of Steatohepatitis in Hepatitis C
Eugene F. Tharalson, Richard D. Gerkm, Francisco C. Ramirez
Heather Patton, Cynthia Behling
Background: Both Child and MELD scores Mve the ability to predict mortality in cirrhosis. Each may optimally do so over a different tinte frame Pttrpose: To compare MELD with Child's scores in their ability predict 90 day and one }*earmortalW, Study design: Retrospective medical record review Methods: The inpauent database was searched from October 1, 2000 through September 30 2001 {br patients with cirrhosis. Medical records were reviewed for mortality and clinical data one year alter admissinn Chdd score was categorized into categories A, B, and C MELD score was categorized into 4 categories as shown m the table Stastical analysis: COX propomonal Hazard analysis Child A and MELD 1 categories were assigned a risk of 1 for the calculation of the tmzard ratio for Child B and C, as well as Meld 2-4 respectively Results: 129 patients ~wereidentified. Mean age 57 years. Mean MELD score 13 Mean Child score 8. MELD score was signihcantly correlated with Child score (R = 0.6, p = 0.0001) Mortality data fer MELD and Child categories are shovm in the table At 90 days, MELD categories 3 and 4 (Hazard ratios: 5.06, and 11.94, p = 0.005) and Child Category C (hazard ratio 305, p = 0 01) were independendy associated with increasing mortality For one year mortality, MELD categories 2, 3, and 4 (p=0.O01) and Child categories B and C (hazard ratios: 9 2 and 20.3, p=0.01) were independently associated with increasing mortality In addition, age was predictive of 90 day and one year mortality independent ot Child category (HR 1 03/year and 1.05/year respectively, p = 0.02), but not independent of MELD score. Conclnsiona: I Child and MELD scores are naeful for the prediction ot naonality in cirThotic patients who are admitted to the hospital. 2. For 90 day mortality, the lower categories (Child A-B, MELD 1-2) were not independently predictive of mnrtality 3 A mathematical model demonstrating whicJh of the tests is more elf}clive tot the prediction ot long and s}mrt term mortality would be useful
Background: Non-alcoholic fatty fiver disease represents a chracopathologic spectrum from bland steatosis to non-alcoholic steatohepatitis (NASH). NASH is a potentially progressive disease with risk for development of fibrosis and cirrhosis. Steatosis is observed in approximately 50% of patients with chronic hepatitis C (HCV) infection but the incidence and clinical significance of concurrent ieatures of NASH are not clear. Aims: We sought to determine the frequency of pathologic features of NASH m biopsies from patients with HCV and compare biopsies with steatosts alone to those with features of NASH. Methods: Pauents with chronic HCV intection were selected fi'om the Scripps Clinic Liver Research Database Liver biopsy specimens were blindly evaluated for the presence and severity of steatosis by two investigators with a high degree of concordance (Kappa 0.84, p<0.005). Steatosis was recorded as a percentage of effected hepatocytes and assigned a l a d e [0 (0-2%), 1 (329%), 2 (30-59%), 3 (->60%)]. Features of steatohepatitis including centrilobular hepatocyte ballooning, perwenular fibrosis, Mallory hyaline, glycogen nnclei, neutrophiI infiltrates and hpogranulomas were noted as present or absent. Inflammatory activity and fibrosis were assessed according to METAV1R. Demographic and laboratory niformation was collected at the time of the liver biopsy. Results: Of the 222 biopsies evaluated, 150 (68%) had steatosis Specific features of NASH (hepatocyte ballooning, Mallory, hyaline and/or perisinusoidal fibrosis) were present in 39/150 (26%) biopsies with steatosis. Eight patients had more than one feature of NASH. Marked hepatocyte ballooning was present only in association with severe steatosis Biopsies with features of NASH were more likely to show high stage fibrosis (Chi Square analysis p = 0.02)and be from male patients (Oh1 Square p = 0.04). Comparison of the histologic features between the group with steatotsis alone and those with [eatures of NASH showed no differences in lobular inflammation, glycogen nuclei, portal inflammation, or grade of steatosLs. Clinical teatures were also similar between those with HCV and steatosis alone and HCV and NASH, with no difference in age, ethnicity, history of diabetes, duration of nifection, current alcohol use or genotype Conclusions: Histologic features of NASH are relatively common in biopsies from patients with HCV and are associated with higher stage fibrosis. Prospective studies may"elucidate the relative contributions of each of these conditions to fibmgenesis.
AASLD Abstracts
A-750
MELD t: 1-9 MELD 2:10-19 MELD 3:20-29 MELD 4:30-39 Child A Child B Child C
n ....... 35 62 14 3
deaths 90 d 5 (14%) 11 (18%) 8 (57%) 2 (67%)
30
0
44 33
11 (25%) 14 (42%I
,,deaths l y
9 (26%) 25 (40%) 10 (71%) 3 (100%) 2 (7%) 20 (45%) 23 (70%}
M1414 HVPG Measurements to Guide Secondary Prophylaxis for Variceal Bleeding: A Decision Analysis Daniel L Raines, Andrew W. Dupont, Miguel R. Arguedas Background & Aims: Measurement of hepatic venous pressure gradient (HVPG) can evaluate response to prophylaxis in patients with a prior variceal bleed (VB) However the costelfl:ctiveness of HVPG measurement to guide secondary prophylaxis has not been examined Methods: A decision analysis tree was constructed (DATA 3.5) Total costs, VB episodes and proportion of patients alive were calculated tot the fbllowing stmtegms: 1) B-blockers without hemodynamic monitoring, 2) Combination B-blockers and nitrates without rnonitornil, 3) HVPG measurement 12 weeks after ininatmg B-blockers, 4) HVPG measurement 12 weeks after initiating combination therapy, 5) HVPG measuremem prior to and 12 weeks after mitiatnig B-blockers, 6) HVPG measurement prior to and 12 weeks after niitiatmg combination therapy, and 7) endoscopic variceal ligation (EVL) Hemodynamic response was defined as: HVPG <12mmHg or a decrease ->20% in HVPG (2 measurements) or an HVPG <12mmHg (1 measurement). Non-responders underwent EVL. Probabilities were obtained from the hterature using Medline. All costs represented Medicare reimbursements at our institution. Drag costs represented the average wholesale price. The time horizon was 1 year. Results: The table shows total costs, proportion of patients with VB and proportion alive at 1 year (in order of increasing costs). After eliminating more expensive and less effective strategies, the two remaining were combnianon therapy without monitornig and combination therapy with 2 HVPG measurements. The incremental cost-effectiveness ratio (ICER) per year of life saved of combination therapy with two HVPG measurements compared to combination therapy without monitoring was $2,274,500, whereas the cost per VB prevented was $5,921. Results were sensitive to the tinte horizon with the ICER of hemodynamic monitoring improving as the time horizon extended and to the probability of hemod D namic response and cost of HVPG. Conclusions: At one year, hemodynamic monitoring with HVPG measurements to guide secondary prophylaxis is an expensive strategy in terms of maximizing patient survival Targeting hemod}mamic monitoring to guide secondary prophylaxis in patients in whom overall survival is expected to be prolonged may be an appropriate strategy.
M1412
Percutaneous Liver Biopsy by the U,S. Gastroenterologists: A Vanishing Skill? Muhammad K Hasan~ Dawd S, Stokesberry, Da'~d M ]hompson, Aura Parra, Sikandar A. Meslya Pu~mse: liver biopsy is commonly performed for the assessment of hepatitis C and other chronic Ever diseases Tradnionally, gastroenterologists (GI) and hepatologists have performed liver biopsy utilizing a variety of methods Over t k past decade radiologists, utilizing real time imaging technique have been increasingly requested by practitioners to perform liver biopsy This sin@ investigates factors that nifluence gastroenterologists and hepatologists decision to perform liver biopsy themseb
cost(us$)
Combination B.,blocker EVL Combination (1 HVPG) B,.blocker(1 I,NPG) ComblnWdon(2 HVIR3) B . ~ e r (2 I'NP6)
M1413
3,201 3,868 4,229 5,g83 5,137 7,750 7,938
....
%vB
17,9 24 24 21.1 21,3 17,1 17,2
, %A,wOyur)
81,4 79,8 79.8 80.6 80,5 81,6 81,5
M1415
Predicting Mortality for Inpatients with Cirrhosis: the Utility of Child@ugh and MELD scores
Histologic Features of Steatohepatitis in Hepatitis C
Eugene F. Tharalson, Richard D. Gerkm, Francisco C. Ramirez
Heather Patton, Cynthia Behling
Background: Both Child and MELD scores Mve the ability to predict mortality in cirrhosis. Each may optimally do so over a different tinte frame Pttrpose: To compare MELD with Child's scores in their ability predict 90 day and one }*earmortalW, Study design: Retrospective medical record review Methods: The inpauent database was searched from October 1, 2000 through September 30 2001 {br patients with cirrhosis. Medical records were reviewed for mortality and clinical data one year alter admissinn Chdd score was categorized into categories A, B, and C MELD score was categorized into 4 categories as shown m the table Stastical analysis: COX propomonal Hazard analysis Child A and MELD 1 categories were assigned a risk of 1 for the calculation of the tmzard ratio for Child B and C, as well as Meld 2-4 respectively Results: 129 patients ~wereidentified. Mean age 57 years. Mean MELD score 13 Mean Child score 8. MELD score was signihcantly correlated with Child score (R = 0.6, p = 0.0001) Mortality data fer MELD and Child categories are shovm in the table At 90 days, MELD categories 3 and 4 (Hazard ratios: 5.06, and 11.94, p = 0.005) and Child Category C (hazard ratio 305, p = 0 01) were independendy associated with increasing mortality For one year mortality, MELD categories 2, 3, and 4 (p=0.O01) and Child categories B and C (hazard ratios: 9 2 and 20.3, p=0.01) were independently associated with increasing mortality In addition, age was predictive of 90 day and one year mortality independent ot Child category (HR 1 03/year and 1.05/year respectively, p = 0.02), but not independent of MELD score. Conclnsiona: I Child and MELD scores are naeful for the prediction ot naonality in cirThotic patients who are admitted to the hospital. 2. For 90 day mortality, the lower categories (Child A-B, MELD 1-2) were not independently predictive of mnrtality 3 A mathematical model demonstrating whicJh of the tests is more elf}clive tot the prediction ot long and s}mrt term mortality would be useful
Background: Non-alcoholic fatty fiver disease represents a chracopathologic spectrum from bland steatosis to non-alcoholic steatohepatitis (NASH). NASH is a potentially progressive disease with risk for development of fibrosis and cirrhosis. Steatosis is observed in approximately 50% of patients with chronic hepatitis C (HCV) infection but the incidence and clinical significance of concurrent ieatures of NASH are not clear. Aims: We sought to determine the frequency of pathologic features of NASH m biopsies from patients with HCV and compare biopsies with steatosts alone to those with features of NASH. Methods: Pauents with chronic HCV intection were selected fi'om the Scripps Clinic Liver Research Database Liver biopsy specimens were blindly evaluated for the presence and severity of steatosis by two investigators with a high degree of concordance (Kappa 0.84, p<0.005). Steatosis was recorded as a percentage of effected hepatocytes and assigned a l a d e [0 (0-2%), 1 (329%), 2 (30-59%), 3 (->60%)]. Features of steatohepatitis including centrilobular hepatocyte ballooning, perwenular fibrosis, Mallory hyaline, glycogen nnclei, neutrophiI infiltrates and hpogranulomas were noted as present or absent. Inflammatory activity and fibrosis were assessed according to METAV1R. Demographic and laboratory niformation was collected at the time of the liver biopsy. Results: Of the 222 biopsies evaluated, 150 (68%) had steatosis Specific features of NASH (hepatocyte ballooning, Mallory, hyaline and/or perisinusoidal fibrosis) were present in 39/150 (26%) biopsies with steatosis. Eight patients had more than one feature of NASH. Marked hepatocyte ballooning was present only in association with severe steatosis Biopsies with features of NASH were more likely to show high stage fibrosis (Chi Square analysis p = 0.02)and be from male patients (Oh1 Square p = 0.04). Comparison of the histologic features between the group with steatotsis alone and those with [eatures of NASH showed no differences in lobular inflammation, glycogen nuclei, portal inflammation, or grade of steatosLs. Clinical teatures were also similar between those with HCV and steatosis alone and HCV and NASH, with no difference in age, ethnicity, history of diabetes, duration of nifection, current alcohol use or genotype Conclusions: Histologic features of NASH are relatively common in biopsies from patients with HCV and are associated with higher stage fibrosis. Prospective studies may"elucidate the relative contributions of each of these conditions to fibmgenesis.
AASLD Abstracts
A-750