Prevalence of septic events, type 1 hepatorenal syndrome, and mortality in severe alcoholic hepatitis and utility of discriminant function and MELD score in predicting these adverse events.

We sought to assess prevalence, and utility of discriminant function (DF) and MELD score in predicting septic events (SE), type 1 hepatorenal syndrome (HRS), and short-term mortality in severe alcoholic hepatitis (AH). Charts of patients with AH (group 1) and cirrhosis without AH (group 2) were retrospectively reviewed. Severe AH, discriminant function (DF) >or= 32 was treated with pentoxifylline. One hundred ninety-five patients were enrolled in the study and divided into 2 groups: group 1, n=99, and group 2, n=96. Of those with AH, 82% had a DF >or= 32 at presentation. Group 1 patients had a higher prevalence of SE (38% versus 25%, P=.04), type 1 HRS (30% versus 9%, P=.0003), and short-term mortality (28% versus 7%, P=.0001). In patients with AH, a MELD score >or=20 (but not a DF >or= 32) at presentation was an independent predictor of a SE (odds ratio [OR] 2.8 [1.0-7.9], P=.04), HRS (OR 4.0, 95% confidence interval [CI] 1.0-16.6, P=0.05), and short-term mortality (OR 6.4, 95% CI 1.1-37.6, P=.03). Kaplan-Meier survival curves confirmed that that a MELD >or= 20 but not a DF >or= 32 was associated with a poorer survival (P = .005 and .5, respectively). In conclusion, patients with severe AH have higher prevalence of SE, HRS, and short-term mortality compared to those with cirrhosis without AH. A MELD score >or=20 at presentation is an independent predictor of these adverse events in patients with AH who have been treated with pentoxifylline.

More advanced hepatic fibrosis in hispanics with chronic hepatitis C infection: role of patient demographics, hepatic necroinflammation, and steatosis.

BACKGROUND AND AIMS: We sought to assess whether Hispanics have more advanced hepatitis C virus (HCV)-related liver disease than non-Hispanic whites (NHW) and to identify contributory factors. PATIENTS AND METHODS: Patients were recruited from the Los Angeles county hepatitis clinic. Liver fibrosis and necroinflammation (NI) were assessed by the Ishak scoring system. Hepatic steatosis was graded as 0-4. RESULTS: A total of 232 patients were evaluated, 63 NHW and 169 Hispanic. Hispanics were older and had a higher prevalence of blood transfusion (40%vs 21%), obesity (body mass index > 30) (47%vs 21%), diabetes mellitus (DM) (16%vs 5%), and hepatic steatosis (79%vs 47%), p < 0.02. Independent predictors of hepatic steatosis were Hispanic ethnicity (odds ratio [OR] 3.8, 95% CI 1.7-8.7, p= 0.001) and obesity (OR 5.7, 95% CI 2.3-14.1, p= 0.0002). Compared with NHW, Hispanics also had higher fibrosis stage (3.3 +/- 2 vs 2.3 +/- 6.9, p= 0.001), NI grade (6.4 +/- 1.8 vs 5.6 +/- 1.6, p= 0.002), and faster fibrosis progression/yr (0.14 +/- 0.09 vs 0.09 +/- 0.07, p= 0.0002). Presence of DM (OR 2.9, p= 0.02), grade 1-2 hepatic steatosis (OR 2.3, p= 0.03), AST/ALT > 1 (OR 4.3, p= 0.01), NI grade (OR 1.7, p < 0.0001), age at biopsy (OR 1.1, p < 0.0001), and serum bilirubin (OR 5.4, p < 0.0001) were independent predictors of fibrosis stage > or =4. CONCLUSION: This study confirms that Hispanics have more advanced hepatic fibrosis than NHW. This is related to older age, higher NI grade, and greater prevalence of hepatic steatosis and DM.

Factors predicting relapse and poor outcome in type I autoimmune hepatitis: role of cirrhosis development, patterns of transaminases during remission and plasma cell activity in the liver biopsy.

AIM: To determine factors predicting relapse and poor outcome in patients with type I autoimmune hepatitis (AIH). METHODS: Patients with AIH were retrospectively recruited. Definitions-remission: AST/ALT < 2 ULN; relapse: AST/ALT > or = 2 ULN; poor outcome: cirrhosis complications, transplantation (OLTx), and death; abnormal transaminases: AST/ALT > ULN but within the remission range; abnormal transaminases index (ATI): number of occasions AST/ALT abnormal/years of remission. Liver biopsies were assessed by Ishak system, and additional score given for portal and parenchymal plasma cells. Data are presented as median (range). RESULTS: Seventy-one patients were identified. Twenty (28%) had cirrhosis at presentation, 14 (20%) developed it during follow-up of 52 months (18-336). Of the 14, four had histological confirmation, and the remainder had clinical/radiological evidence of cirrhosis. Factors independently associated with cirrhosis development were inability to have consistently normal transaminases during remission, OR 19.3 (95% CI 2.2-40), p = 0.002. Treatment was discontinued in 40/69 patients of whom 30 (75%) relapsed within 2 months (1-23), culminating in one death. Factors independently associated with relapse were: time to initial remission, OR 5.5, 95% CI 1.3-22, p = 0.01; failure to have consistently normal transaminases during remission OR 11.8, 95% CI 1.3-100, p = 0.02; and portal plasma cell score (PPCS) OR 10.6 (95% CI 1.0-107), p = 0.04. Time to remission > or = 5 months, PPCS > or = 3 and ATI > or = 2 was associated with > 90% probability of relapse (PPV 100%). Fifteen percent had a poor outcome. Independent predictors of poor outcome were: globulins at onset OR 3.4 (95% CI 1.1-10.1), p = 0.02 and cirrhosis development, OR 23 (95% CI 1.7-307), p = 0. CONCLUSIONS: Seventy percent of patients with AIH relapse upon drug cessation. Time to remission > or = 5 months, ATI > or = 2 and PPCS > or = 3 were associated with > 90% probability of relapse. Factors predicting poor outcome were globulins at onset and cirrhosis development.

Clinical Profiles of Chronic Hepatitis C in a Major County Medical Center Outpatient Setting in United States.

The estimated prevalence of hepatitis C virus (HCV) infection in the US is 1.8 %. Data are limited on the clinical profile of the disease at first presentation and dynamic follow-up of ALT level, especially in publicly-funded patients. This information is critical for optimal management of these patients. The present study is aimed to assess the clinical profiles of chronic hepatitis C (CHC) at first presentation and clinical implication of dynamic follow-up of ALT level in a county medical center setting. A total of 294 patients were selected from the population consecutively evaluated in the Hepatitis Clinic at Los Angeles County-USC Medical Center between Jan. 1990 and Dec. 1998. Ethnicity of the patients was Hispanics-49.0%, Caucasian-28.6%, African American-13.6%, and Asian-8.8%. Risk factors were identifiable in 84.0% of patients, and injection drug use (IDU) represented the leading risk factor for HCV acquisition (47.4%). History of alcoholism was present in 39.1%. The initial clinical diagnoses were chronic hepatitis 76.9%; compensated cirrhosis 20.4%; and decompensated cirrhosis 2.7%. Elevation of ALT, alpha fetoprotein (AFP), ferritin, and anti-nuclear antibody (ANA) titer were seen in 219/294 (74.5%), 60/194 (30.9%), 20/83 (24.1%), and 35/97 (36.1%) patients, respectively. Anti-HBc (total) test was positive in 65/129 (50.5%) patients. The presence of cirrhosis was significantly associated with age greater than 55 years at entry, female gender, non-African American ethnicity, history of transfusion, lower level of albumin and elevated level of AFP. Longitudinal observation of ALT changes in 178 patients who had neither evidence of cirrhosis at entry nor received interferon treatment showed persistently normal, intermittently or persistently elevated ALT level in 15.2%, 38.3%, and 46.6% patients, respectively. The frequency of developing clinical evidence of cirrhosis during follow-up was significantly higher in patients with persistently (16.0%) or intermittently (7.0%) elevated ALT than that in patients with persistently normal ALT (4.0%). In conclusion, the present study analyzed the clinical profiles of CHC, assessed risk factors for developing cirrhosis, and demonstrated the clinical value of dynamic follow-up of ALT level in a cohort of publicly-funded patients. These data have major implications in designing optimal strategies for disease management, antiviral therapy, and screening for hepatocellular carcinoma in patients with CHC.