Primary biliary cirrhosis: survival of a large cohort of symptomatic and asymptomatic patients followed for 24 years

We extended by 10 years, a follow-up study of 279 patients with primary biliary cirrhosis initially evaluated at the Yale Liver Study Unit between 1955 and 1979. Thirty-six patients (13%) were asymptomatic at the time of diagnosis. Accurate follow-up survival data were available for 247 patients (89%), ranging up to 24 years after the original diagnosis. Median predicted survival of patients in this study from the time of diagnosis is twice as long for patients who present without symptoms compared to symptomatic patients (16 vs 7.5 years, p < 0.0001). However, overall survival of those asymptomatic patients is shorter than that predicted for an age- and gender-matched control population (p < 0.0001), a difference that became apparent only after 11 years of follow up. With a median follow up of 12.1 years, 33% of the asymptomatic patients remained free of symptoms of liver disease, However, once symptoms develop, their survival is similar to those presenting with symptoms. Independent predictors of diminished survival include: elevated bilirubin, increasing age, ascites, advanced fibrosis and the degree of portal bile stasis on liver biopsy. It was not possible to predict which asymptomatic patients would remain symptom free.

Is there recurrence of primary biliary cirrhosis after liver transplantation? A clinicopathologic study in long-term survivors

Liver transplantation has been accepted as a successful therapeutic tool for irreversible liver diseases such as primary biliary cirrhosis. However, removal of the diseased liver may not eliminate this autoimmune disease, and recurrence of primary biliary cirrhosis in the liver graft has been reported as early as within the first posttransplant year. We studied whether or not primary biliary cirrhosis recurs after liver transplantation in follow-up biopsies of 19 primary biliary cirrhosis patients. Biopsies of 14 non-primary biliary cirrhosis patients served as controls. The median follow-up period was 5 years (range 1-11 years). Both groups of patients were selected according to strict criteria which excluded pre- and posttransplant diseases which could mimic primary biliary cirrhosis. The follow-up biopsies were taken according to a protocol at yearly intervals. Established histologic criteria for primary biliary cirrhosis were assessed semi-quantitatively in 119 biopsies in a coded fashion. A longitudinal study was performed after decoding the biopsies, to document the course of morphological changes in time per patient. In addition to data on liver tests and immunosuppression, anti-mitochondrial antibodies including the primary biliary cirrhosis specific subtypes (anti-PDH-E2 and BCKD-E2) were determined in freeze-stored serum samples. The biopsies showed a striking concordance between the primary biliary cirrhosis and non-primary biliary cirrhosis groups and few overt histologic abnormalities. There was no significant difference in liver-test results and immunosuppression. Overall anti-mitochondrial antibodies remained present in decreased titers.(ABSTRACT TRUNCATED AT 250 WORDS)

Practical problems in fitting a proportional hazards model to data with updated measurements of the covariates

We review and discuss the practical problems encountered when analysing the effect on survival of covariates which are measured repeatedly over time. Specific issues arise over and above those met with the standard proportional hazards model and concern all stages of data preparation, data analysis and interpretation of the results. Data from a randomized clinical trial of patients with primary biliary cirrhosis, on whom several measurements were taken at regular intervals after entry, are presented as an illustration.

The role of hepatitis C virus in hepatocellular carcinoma in Japan

Increasing numbers of patients with hepatocellular carcinoma (HCC) have been reported in Japan. In this paper, we investigated the role of hepatitis C virus (HCV) in HCC and the reason for the increase, using patients admitted to our university hospital from 1945 to 1992. 99 (73%) of 135 patients with HCC were positive for anti-HCV. Prospective studies demonstrated that 22 of 158 (14%) patients with chronic hepatitis C, and 31 of 70 (44%) cirrhotic patients with anti-HCV developed to HCC during the follow-up period (10.1 +/- 3.3 and 7.3 +/- 3.5 years, respectively). Prolonged survival of cirrhotic patients during past decades would also contribute to the increasing number of HCC cases as well as the number of HCV infections in Japan.

Updating prognosis in primary biliary cirrhosis using a time-dependent Cox regression model. PBC1 and PBC2 trial groups

BACKGROUND

The precision of current prognostic models in primary biliary cirrhosis (PBC) is rather low, partly because they are based on data from just one time during the course of the disease. The aim of this study was to design a new, more precise prognostic model by incorporating follow-up data in the development of the model.

METHODS

We have performed Cox regression analyses with time-dependent variables in 237 PBC patients followed up regularly for up to 11 years. The validity of the obtained models was tested by comparing predicted and observed survival in 147 independent PBC patients followed for up to 6 years.

RESULTS

In the obtained model the following time-dependent variables independently indicated a poor prognosis: high bilirubin, low albumin, ascites, gastrointestinal bleeding, and old age. When including histological variables, cirrhosis, central cholestasis, and low immunoglobulin (Ig)M also indicated a poor prognosis. The survival predicted by the models agreed well with the survival observed in the independent PBC patients. The time-dependent models predicted better than our previously published time-fixed model.

CONCLUSIONS

Using the time-dependent Cox models, one can estimate a more precise probability of surviving the next 1, 3, or 6 months for any given patient at any time during the course of the disease. This may improve monitoring of PBC patients.

Regression dilution in the proportional hazards model

The problem of regression dilution arising from covariate measurement error is investigated for survival data using the proportional hazards model. The naive approach to parameter estimation is considered whereby observed covariate values are used, inappropriately, in the usual analysis instead of the underlying covariate values. A relationship between the estimated parameter in large samples and the true parameter is obtained showing that the bias does not depend on the form of the baseline hazard function when the errors are normally distributed. With high censorship, adjustment of the naive estimate by the factor 1 + lambda, where lambda is the ratio of within-person variability about an underlying mean level to the variability of these levels in the population sampled, removes the bias. As censorship increases, the adjustment required increases and when there is no censorship is markedly higher than 1 + lambda and depends also on the true risk relationship.

Primary biliary cirrhosis. Histological evidence of disease recurrence after liver transplantation

Histological evidence of primary biliary cirrhosis (PBC) recurring after orthotopic liver transplantation (OLT) was looked for in a 'blinded' study of 353 biopsies from 188 patients, 12-100 months post-transplant. Biopsies (172) were obtained from 83 patients transplanted for PBC and 181 biopsies from 105 patients with other liver diseases. Sixteen biopsies from 13 PBC patients (16%) had features suggestive of recurrent disease. The main diagnostic findings were: mononuclear portal inflammatory infiltration (n = 16), portal lymphoid aggregates (n = 14), portal epithelioid granulomas (n = 14) and bile duct damage (n = 15). This combination of changes was not seen in any biopsy from the non-PBC group. Additional features supporting a diagnosis of recurrent disease were ductopenia (n = 7), bile ductular proliferation (n = 7), portal fibrosis (n = 6) and copper deposition (n = 5). Thirteen biopsies from 12 patients were classified as stage I or II histologically. The other patient developed progressive damage in three serial biopsies resulting in an early micronodular cirrhosis, 5 years post-transplant. These observations provide further evidence that PBC recurs after OLT. More studies are required to determine the natural history and clinical significance of the predominantly early histological changes documented so far.

Liver transplantation for primary sclerosing cholangitis versus primary biliary cirrhosis: a comparison of complications and outcome

Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) are the most common cholestatic disorders in adulthood requiring hepatic transplantation. Although they run similar courses, they may have different problems before and after transplantation. The aim of this study was to compare pre- and post-transplant complications and outcomes in these two similar but distinct patient groups. One hundred and seventeen adult patients underwent liver transplantation at our institution over a 6 year period, including 19 with PSC and 20 with PBC. Pre-transplant there were no significant differences in age, liver biochemistry, haematology or Child-Pugh scores between the two groups. The mean duration of disease before transplant was longer in PSC patients (11.7 vs 6.5 years; P < 0.05). The prevalence of septic cholangitis was greater in PSC (58 vs 5%; P < 0.01) as was the requirement for surgical or radiological interventional procedures, excluding cholecystectomy (53 vs 0%; P < 0.01). At transplantation, four patients with PSC had previously unrecognized cholangiocarcinoma. In the pre-transplant period these four patients had uncontrolled biliary sepsis at the time of transplant vs five of 15 PSC patients without cholangiocarcinoma. Postoperatively, PSC patients had a greater prevalence of intra-abdominal sepsis requiring surgical or radiological intervention (42 vs 5%; P < 0.05). In comparison, patients with PBC had a high prevalence of skeletal complications (30 vs 10%; P < 0.05) particularly avascular necrosis (15 vs 0%). The prevalence of chronic rejection was similar in both groups (15%). Overall survival was higher in PBC patients (85 vs 63%; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Definitive surgical treatment of cholelithiasis in selective patients with liver cirrhosis

A review of 132 cirrhotic patients with cholelithiasis was carried out. Of the 87 patients who underwent definitive surgical procedures for gallstones, patients of Child's A grade had less operative blood loss, blood transfusion and shorter hospital stay than those of B and C grades. No mortality in cirrhotic patients with Child's A and B grade was found in both emergency and elective surgery. Emergency operation in patients with Child's C grade resulted in more operative blood loss and requirement than elective surgery. Patients in this grade had also a higher morbidity rate and four deaths ensued. Of the 83 survivals after definitive procedures, 78 patients (93.9%) were still alive in the following 62.8 months without any biliary tract symptoms. Of patients who survived after cholecystolithotomy, 6 patients (33.3%) had recurrent stones in the same follow-up period. Therefore, we recommend that definitive biliary surgery be selectively carried out in cirrhotic patients in Child's A and B grade. However, a conservative approach is more suitable in Child's C patients in emergency conditions and definitive procedures should be considered when their liver function improves.

[Liver transplantation as a routine procedure? Indications and results in 270 patients]

AIM

To represent the current state of the art of orthotopic liver transplantation (OLT). The constantly expanding spectrum of indications are discussed in detail, and the specific risks of the individual indications considered. Major points discussed: On the basis of the authors' own results obtained at the Rudolf Virchow Hospital, University of Berlin, the current survival rates following orthotopic liver transplantation are shown. In addition to established indications for liver transplantation (primary biliary cirrhosis, primary sclerosing cholangitis, acute hepatic failure, various metabolic diseases, small hepatocellular carcinomas and a number of posthepatic cirrhoses) the indication and results of liver transplantation in HbsAg-positive and alcoholic cirrhosis are presented in detail. In contrast to reports in the Anglo-American literature, the incidence and severity of graft re-infections with the hepatitis virus was appreciably reduced through the use of anti-HBs hyperimmunoglobulin preparations in HBsAg-positive cirrhotics. The results obtained were comparable with those achieved for other indications.

Cyclosporin A treatment in primary biliary cirrhosis: results of a long-term placebo controlled trial

BACKGROUND

Effective treatment for primary biliary cirrhosis (PBC) resulting in slower progression and improved survival remains elusive. Cyclosporin A (CyA), which has been so effective in preventing human allograft rejection, has shown promise in small numbers of patients in early studies.

METHODS

Three hundred forty-nine patients with PBC were randomized to receive CyA, 3 mg.kg-1.day-1, or placebo in a multicenter study with follow-up for 6 years. The end point was death or liver transplantation.

RESULTS

Cox multivariate analysis showed time from entry to death or transplantation was significantly prolonged (by up to 50%) in the CyA-treated group. Liver-related mortality was also significantly lower. However, a univariate analysis of survival showed no statistical differences between the two groups. Biochemical liver indices deteriorated more slowly in the CyA-treated group, but serum creatinine concentration was elevated > 150 mumol/L in 9%, necessitating permanent discontinuation in half of these. A reduction in the dose of CyA was required in 11% because of hypertension.

CONCLUSIONS

CyA has some therapeutic potential in primary biliary cirrhosis, providing blood pressure and renal function are closely monitored.

The results of a randomized double blind controlled trial evaluating malotilate in primary biliary cirrhosis. A European multicentre study group

One hundred and one patients were included in a double-blind controlled trial to determine whether malotilate (diisopropyl 1,3-dithiol-2-ylidene malonate) is therapeutically effective in primary biliary cirrhosis. Fifty-two patients received malotilate (500 mg three times a day) and 49 patients placebo. The mean follow-up time was 28 months (range 6-46 months). The large majority of patients did not have advanced liver disease since only ten patients were in Child-Pugh class B and none in class C, and the median bilirubin and albumin at entry were normal. Malotilate had no clear effect on pruritus. In malotilate recipients the following statistically significant biochemical changes occurred: alkaline phosphatase decreased 21%, AST 20%, ALT 40%, IgA 12% and IgM 26%. In the placebo group no significant changes occurred. Evaluation of entry and 2-year liver biopsies indicated that malotilate diminished plasma cell and lymphocytic infiltrate and piece-meal necrosis, but had no effect on liver fibrosis. There was no difference in survival or in disease progression according to Child-Pugh criteria. In six patients receiving malotilate, but in none on placebo, treatment was discontinued due to suspected side effects. All patients recovered completely. We conclude that malotilate has an immune-modulating, anti-inflammatory but not anti-fibrotic effect in primary biliary cirrhosis. The clinical relevance of the observed benefits, however, appears too slight to recommend malotilate as single drug therapy in primary biliary cirrhosis.

Prediction of short-term survival with an application in primary biliary cirrhosis

Many long-term follow-up studies for survival accumulate repeated measurements of prognostic factors. Survival models which include only covariate values at baseline do not use all available information, and do not relate to survival predictions for times other than at that baseline. Time-dependent covariate models (which update covariate values as measurements occur through time) might be used, though limitations of software for estimating the underlying hazard functions and difficulty in relating hazard function changes to survival prediction present serious drawbacks. By dividing each patient's follow-up into successive intervals of equal length (using a length of interest for prediction) and with measurements available at the start of each, we describe how an analysis taking person-intervals as the observation units can be undertaken using readily available software to produce short-term survival models. We show that this approach is related to both the baseline and time-dependent covariate models. The method is illustrated using data from a long-term study of patients with primary biliary cirrhosis, where interest is in short-term survival predictions to aid the decision when to undertake liver transplantation.

A controlled trial of prednisolone treatment in primary biliary cirrhosis. Three-year results

The results of a 3-year, placebo-controlled trial of prednisolone treatment in primary biliary cirrhosis (PBC) are presented. The active (n = 19) and placebo (n = 17) arms were initially well matched for age, menopausal status and disease severity. At 3 years hepatic symptoms were relatively improved in the prednisolone group. Hepatic mortality was 3/19 (prednisolone), 5/17 (placebo) (p = n.s.). For all liver blood tests the trend favoured prednisolone treatment, though the differences were only significant for alkaline phosphatase and protein. All immunoglobulins fell significantly. Quantitative ELISA determination of antimitochondrial antibody showed a significant fall in the prednisolone group compared with placebo (p less than 0.001 at 1 year, p less than 0.05 at 3 years). Deterioration in histology (appearance of cirrhosis) was more common in the placebo group. Overall hepatic function (hepatic mortality, doubling in bilirubin, 6 milligrams fall in albumin, de novo appearance of cirrhosis or symptoms of portal hypertension) was significantly worse in the placebo group (p less than 0.01). After 3 years no significant differences could be detected in bone mineral content (single photon absorptiometry of radius and femur) between the two groups or in comparison with other PBC patients. Thus, after 3 years, prednisolone treatment was associated with a better overall hepatic outcome and little evidence of increased bone loss.

[Extrahepatic bile duct atresia. Comparison of surgical and non-surgical therapy]

In recent years hepatoportoenterostomy according to Kasai undoubtedly was the only successful therapy for extrahepatic biliary atresia. Since liver-transplantation becomes more successful than previously, the question arises if the Kasai procedure is still justified. From this point of view a prospective study was started based on the following findings in 15 EHBA-children after hepatoportoenterostomy compared to those in 15 patients without the Kasai procedure: the survival rate at the end of two years of life; the development of ascites until the end of the first year of life; the weight and length percentiles at the end of the first year of life; and the activity of serum cholinesterase. In order to calculate significant differences in weight and length percentiles, the exact Fisher test was used. Serum cholinesterase activities of both the above mentioned groups were compared with each other, as well as with the normal values of a third group of 50 healthy children, by analyzing variances and then comparing one by one with adjustment for multiple comparisons. There was a significant difference between the operated and not-operated group, and in addition between the non-operated and the healthy group. In contrast, no significant difference was detected between the operated and the healthy group. These differences were best demonstrated by the findings of weight and length percentiles and the activity of serum cholinesterase. From this we conclude sofar hepatoportoenterostomy undoubtedly is standard procedure in the treatment of EHGA. However, if the Kasai procedure fails or the liver disease progresses to a greater extent, liver transplantation will become the method of choice.

Estimation of survival probability in cirrhotics. Evaluation of a computer model applicable for decision-making

In 25 randomly selected, non-alcohol-induced cirrhotics, a simple mathematical model originally designed as the "Mayo-model" for the prediction of prognosis and survival in patients with primary biliary cirrhosis, was applied using a newly developed computer program. The calculated risk scores were 4.91 for surviving patients compared to 7.65 for those who died (P less than 0.001). The survival probability at the end of the follow-up period was 88% vs 47% (P less than 0.001) for these two groups. In 12 patients of the total of 25, multiple values were calculated at yearly intervals. Usually these R values increased except in one patient with chronic active hepatitis treated effectively with corticosteroids, and for 2 others during the correction of vitamin K deficiency. Our data suggest that this model, originally designed for and validated in patients with primary biliary cirrhosis, may also be applied to predict survival in other non-alcohol-induced cirrhotics and therefore may be applicable in prospective controlled trials in cirrhotics or in evaluating the need for and the timing of liver transplantation in the (near) future in these patients.

Prediction of survival of patients with primary biliary cirrhosis. Examination of the Mayo Clinic model on a group of patients with known endpoint

Increasing use of liver transplantation and new treatment regimens necessitate an accurate estimate of prognosis in primary biliary cirrhosis. To test the usefulness of the Mayo model for this purpose, the R value of the model was calculated for a group of 28 patients after each patient encounter and plotted against time. The data were best described by two linear regressions. For the period 10-2 years before death, the average increase in R value was 0.23 annually [R = 7.1-0.23 x time (in years)]. In the last 2 years of life, the average increase in R value was 1.4. This period could be fit by the expression R = 8.2-1.4 x time (in years). The increase in R value represents the natural progression of primary biliary cirrhosis and can be used for evaluating treatment of patients.

Primary biliary cirrhosis: relation between hepatic function and pulmonary function in patients who never smoked

We studied the relationship between selected variables of hepatic and pulmonary function in 47 patients with primary biliary cirrhosis, who were participating in a prospective study to assess sequential pulmonary function at yearly intervals. An additional 20 patients with primary biliary cirrhosis, who were liver transplant candidates awaiting transplantation, were studied. None of the 67 patients ever smoked cigarettes. Severity of primary biliary cirrhosis was characterized by histological stage and the Mayo risk score derived from a Cox regression model that used the following variables: serum bilirubin and serum albumin levels, age, prothrombin time and clinical severity of edema. Pulmonary function assessment included key variables describing expiratory airflow (forced expiratory volume in 1 sec divided by forced vital capacity) and efficiency of gas exchange (steady-state diffusing capacity for carbon monoxide). We found a significant relationship between histological stage of primary biliary cirrhosis and steady-state diffusing capacity (p = 0.02) and between the Mayo risk score for disease severity and steady-state diffusing capacity (p = 0.03). Progressive deterioration of steady-state diffusing capacity was associated with increasing severity of primary biliary cirrhosis. No relationship existed between pulmonary function and the presence of sicca complex or Sjögren's syndrome or the clinical manifestations of portal hypertension (e.g., esophageal varices, ascites and splenomegaly). No significant relationship existed between expiratory airflow and severity of primary biliary cirrhosis. We conclude that in patients with primary biliary cirrhosis who have never smoked, a statistically significant relationship exists between the severity of the liver disease and the efficiency of gas exchange measured by steady-state diffusing capacity.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary biliary cirrhosis in the elderly

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease with onset about menopause. To investigate its clinical features and the natural history in relation to age, we examined 86 consecutive patients with PBC (81 F, 5 M); 70 were less than 65 years (mean age 48 years) and 16 greater than 65 years (mean age 69 years). All patients were followed-up for 6 months-16 years (mean 4 years). Histological stage at presentation was comparable in the two groups, but among aged PBC subjects there was a significantly higher prevalence of asymptomatic patients (56% vs 24%, p less than 0.001). No significant differences were observed in the biochemical indices and immunological abnormalities. Survival curves showed no significant differences in PBC according to the age. Mortality was observed only in the group less than 65 years (15/70, 21.4%). In conclusion, the large proportion of asymptomatic subjects in the elderly PBC patients accounts for the similar survival in the two groups of patients.

Prognosis in primary biliary cirrhosis. A review

Recent progress has been made in estimating prognosis in primary biliary cirrhosis using Cox models. These models have also demonstrated the therapeutic value of liver transplantation by comparing the observed survival for a group after transplantation with the expected survival without transplantation calculated from the Cox prognostic model. However, good risk patients and those not transplanted principally for hepatocellular failure may not have a survival advantage for many years. Cox models have several limitations: the selection criteria for the patient populations used to derive the models, the selection of the time at which the patients are evaluated, the poor prognostic accuracy for individual patients rather than patient groups and lastly the fact that they use variables derived at only one time point-time independent Cox models. Thus new statistical tools must be used to improve prediction of survival in individual patients with PBC in order to optimize timing of liver transplantation. In addition a more precise definition of the natural history of both symptomatic and asymptomatic forms of this disease is needed to evaluate the efficacy of therapeutic agents in randomized clinical trials. However, although use and timing of therapeutic intervention, including liver transplantation, still requires good clinical experience and judgement, statistical modelling does give some objective measurement of prognosis, which is useful for the clinician treating patients with PBC. At the same time that new treatments are being evaluated, there is an obvious need to improve prognostic tools for application to individual patients with PBC. This may be achieved by using serial data in a different form of modelling-time dependent Cox models.

[Primary biliary cirrhosis. The clinical experience in 31 patients]

We analyzed 31 patients with a diagnosis of primary biliary cirrhosis, 29 of them males, aged 23 to 72 years. Liver biopsy was diagnostic in all showing initial findings of the disease in 5. Echotomography and cholangiography demonstrated a patent biliary, tract. Anti-mitochondrial antibodies were present in 94% of patients. Alkaline phosphatase and biliary acid levels were useful for diagnosis. Pruritus was present with varying intensity in all patients, with premenstrual exacerbations in 5 females who had cholestasis of pregnancy or hepatitis caused by progestin drugs before developing cirrhosis. Recurrent urinary tract infection was present in 8 patients, osteoporosis in 24, Sjogren's syndrome in 24 and Crest syndrome in 4. Survival ranged from 1 to 12 years, death being caused by ruptured esophageal varices in 12 patients and by liver failure in 7. Persistence of pruritus and altered liver function tests after cholestasis of pregnancy or hepatitis caused by progestins should lead to investigation of biliary cirrhosis.

Primary biliary cirrhosis: clinicopathological characteristics and outcome

Thirty-five patients with primary biliary cirrhosis were seen between 1974 and 1989. The median mean age at presentation was 53 years (range: 30-77) and the female to male ratio was 7.8:1. Thirteen (37%) were asymptomatic and nine (26%) had associated auto-immune disorders. Pruritus and hepatomegaly were present in half of the patients. Advanced histological stages of disease (Stages 3 and 4) were present in 57% of patients. The median period of follow-up was 5 years (range: 0.1-20). Twelve patients died, nine from hepatic causes and three from non-hepatic causes. One has undergone liver transplantation. A Kaplan-Meier curve estimated the median survival to be 11 years. Asymptomatic patients developed progressive disease and survival was similar to that of symptomatic patients. Using Cox's proportional hazards model, age, serum bilirubin and serum albumin were found to be independent prognostic variables correlating with reduced survival.

[The prognostic factors and evolution of the quality of life in primary biliary cirrhosis]

The prognostic factors and the evolution of the quality of life were evaluated in 38 patients with primary biliary cirrhosis (94.7% females, mean age 52.6 +/- 2.0 years) followed up for more than 36 months (mean 65.3 +/- 3.7 months). Karnofsky's index significantly declined during follow up (p less than 0.05) in a parallel fashion to modified Child's hepatic functional class (p less than 0.05) and to the days of hospital readmission (p less than 0.05). Eleven patients (28.9%) died, and the median survival was 88.7 months. The comparison of the actuarial curves showed the following to be significant poor prognostic factors at the time of diagnosis: a) clinical: more than one associated autoimmune disease, weight loss of more than 10% of the ideal weight, jaundice, upper gastrointestinal hemorrhage associated with portal hypertension, portal-systemic encephalopathy and a modified Child's hepatic functional class of 9 or more; b) biochemical: serum albumin lower than 3.5 g/dl and bilirubin higher than 2 mg/dl; c) histological: Total histological activity index of 10 or more and erosive necrosis index of 2 or more (Knodell et al.), lobular granulomas, and stage IV (Ludwig et al). A significant correlation was found (p less than 0.001) between the R index of the Mayo Clinic and the mean survival time of our patients. As a temporary policy, we indicate hepatic transplant when R is 9.2 or higher (life expectancy lower than 24 months), awaiting our own probabilistic prognostic model with the inclusion of quality of life criteria.

Referral of patients with primary biliary cirrhosis for liver transplantation

All patients with primary biliary cirrhosis referred to this unit for consideration for transplantation between April 1981 and January 1989 were analysed retrospectively to assess whether disease stage at referral affects the outcome after grafting and whether greater awareness of the benefits of the procedure means that patients are now being referred at an earlier stage. Seventy of the 107 patients have been grafted, with an overall one year actuarial survival of 62%. A better prognosis at the time of referral, as assessed by both serum bilirubin concentration and a mathematically derived prognostic index, was associated with a greater probability of survival after grafting. Patients in the tertile with the best prognosis (median serum bilirubin concentration at referral 84 mumol/l and estimated survival in the absence of transplantation of more than nine months) had a 78% one year actuarial survival after transplantation, whereas those in the tertile with the worst prognosis (median serum bilirubin concentration 467 mumol/l and estimated survival of less than four months) had a one year actuarial survival of only 50%. No trend towards earlier referral of patients, however, was shown using either of these two markers. This retrospective analysis suggests that many patients are being referred too late for an optimal outcome. We recommend that patients with primary biliary cirrhosis who are potential candidates for liver grafting should be referred to a transplant centre before the serum bilirubin concentration approaches 150 mumol/l.

Symptom development and prognosis in primary biliary cirrhosis: a study in two centers

The prognosis of patients with asymptomatic primary biliary cirrhosis has been uncertain. Cases of primary biliary cirrhosis in 95 patients from two centers are presented: 70 patients from a regional referral center (Freeman Hospital, FH) and 25 from an international tertiary referral center (King's College Hospital, KCH) with similar mean age at diagnosis and duration of follow-up (median, 12 months). During follow-up, 19 of 70 FH patients and 15 of 25 KCH patients developed symptoms (P less than 0.001); the mean time to symptom appearance was 43 months at FH and 35 months at KCH (P = 0.0012). Twenty-five of 95 patients died, 15 of 34 subjects who had developed symptoms (all liver-related deaths) and 10 of 61 who remained asymptomatic (all non-liver-related deaths) (P less than 0.001). Hepatic mortality was worse than among the normal population (P less than 0.05). A comparison of those patients developing symptoms with 111 at FH and 165 at KCH who presented with symptoms suggests no difference in survival once hepatic symptoms appear. In both centers, hepatic mortality was strongly related to symptom appearance in asymptomatic primary biliary cirrhosis: patients developing symptoms resemble those with symptoms at presentation. Other differences between the centers may reflect different referral patterns.

Diminished survival in asymptomatic primary biliary cirrhosis. A prospective study

Data from 73 asymptomatic patients with primary biliary cirrhosis were analyzed to determine clinical course and long-term survival. Of these, 44 entered a D-penicillamine treatment trial; 29 qualified but chose not to participate. Median follow-up was 7.6 yr (range, 2.8-12.2 yr). Liver biopsy at the initial visit showed advanced disease (fibrosis, cirrhosis) in 61% of the patients. During prospective clinical follow-up, which was available for 37 of the 44 study patients, one or more symptoms of liver disease developed in 33 (89%); esophageal varices were found in 15 (41%), and histologic progression to cirrhosis was found in 20 (67%) of the 30 precirrhotic patients. Significant (p less than 0.01) biochemical progression was reflected by a decrease in mean serum albumin concentrations and an increase in mean serum bilirubin levels in 32 patients followed for 4-6 yr. Survival data were available for all 73 patients; 17 died (11 secondary to liver failure), and 1 underwent liver transplantation. These patients had a 4-fold increase in mortality rate (p less than 0.001) compared with the U.S. population matched for age, race, and sex.

[Primary biliary cirrhosis--analysis of clinical material]

The analysis is presented of 67 patients with primary biliary cirrhosis treated in the years 1971-1988. The group consisted of 60 women (89.5%) and seven men (10.5%). Presenting symptoms were mostly itching (66%) and jaundice (12%). The time between the onset of the first symptoms and the diagnosis was three years, on the average. Autoantibodies to mitochondria were present in 86% of patients. In 27% of cases markers of HB virus infection were found. Cholelithiasis was present in 19 patients (28%). Primary biliary cirrhosis was diagnosed with delay. Third degree of histological changes was observed in 38.8% of cases and in 18% of patients it was already fourth degree. Eighteen patients (27%) died after six years, on the average, from the onset of symptoms. The direct causes of death were, most frequently, liver failure and haemorrhage from oesophageal varices.

Validation of prognostic models in primary biliary cirrhosis

Prognostic models in primary biliary cirrhosis have been validated for large population groups but the predictive value for individual patients has not been tested. We used data from ten deceased patients with primary biliary cirrhosis to test three prognostic models: the Shapiro model (bilirubin); the Christensen model (age, bilirubin, albumin, presence of cirrhosis or cholestasis, azathioprine treatment); and the Dickson model (age, bilirubin, albumin, prothrombin time, oedema). The predictive value of each model for individual patients was determined by assessing whether it would have accurately predicted appropriate timing of liver transplantation in patients prior to death. The Dickson model predicted that four of nine cases would have been considered for liver transplantation one year before death and one of seven cases two years before death. The Christensen model predicted that this procedure would have been considered in three of seven cases two years before death. The Shapiro model was demonstrated to be the least predictive of the three tested. Although none of the three models assessed was found to accurately predict survival, no model predicted a worse survival than actually occurred. Liver transplantation is indicated in those cases with a poor predicted survival.

Use of prognostic models for assessment of value of liver transplantation in primary biliary cirrhosis

To examine the effectiveness of liver transplantation (LTx) for the treatment of primary biliary cirrhosis (PBC) the actual survival of 30 PBC patients who received liver grafts was compared with predictions of what survival would have been without transplantation. Three models, based on Cox' regression analysis, were used. Two models were derived from survival of PBC patients in drug trials and the third from cirrhotic patients who did not receive transplants. Observed and expected survival were compared for a follow-up time of 7 years. After 1 year the difference in favour of LTx was small, but after 5 years survival with LTx exceeded all predicted survival probabilities without LTx. After 3 years every year of follow-up added about 0.3 years to expected survival gain per transplanted patient, resulting in 1.5 to 2.3 life-years gained at 7 years' follow-up, depending on the model used. The benefit was greatest for patients in Child-Pugh classes B and C. The consistency between the three models in their predictions supports the validity of the use of predictive models in the indirect assessment of LTx.

Epidemiology of primary biliary cirrhosis in a defined rural population in the northern part of Sweden

The northern part of Sweden is sparsely populated and must be regarded as a rural region. An investigation into the incidence and prevalence of primary biliary cirrhosis was conducted and the course of the disease was followed. In total, 111 patients with primary biliary cirrhosis were identified for the 10-yr period 1973 to 1982 in the northern health region of Sweden. The mean annual incidence amounted to 13.3 per million and the point prevalence was 151 per million, which is the highest reported so far. There was a significantly higher prevalence in the most northern county of Sweden, both with respect to total number of primary biliary cirrhosis patients and symptomatic patients. Asymptomatic patients amounted to 37%. During the study period 25 patients out of the 111 died (23%), 14 as a direct consequence of the liver disease. Three patients died of primary hepatocellular carcinoma, one having an asymptomatic liver disease without cirrhosis. Primary biliary cirrhosis seems to be more common in Sweden, especially in the northern part, than it is elsewhere. A high frequency of extrahepatic symptoms (85%), mainly musculoskeletal, was recorded. These symptoms may lead to the first contact with the health service, rather than signs of liver disease. Thus, an increasing number of patients are diagnosed with asymptomatic liver disease, who must be followed to check for the eventual development of symptoms.

Factors of prognostic importance in primary biliary cirrhosis

To determine survival and the risk factors of death in primary biliary cirrhosis, data from 52 symptomatic and 13 asymptomatic patients were analyzed. The mean follow-up time was 6.3 years (range, 0.4-23 years). The average length of survival was 18 years for the symptomatic and 8.4 years for the asymptomatic patients. By a univariate analysis, ascites, presence of esophageal varices, gastrointestinal bleeding, jaundice, hepatomegaly and the logarithms of albumin and bilirubin were all associated with a poor prognosis. A multivariate analysis of the clinical features showed that the presence of bleeding from esophageal varices and the logarithm of bilirubin were the only predictors for poor prognosis. The survival of the symptomatic patients is longer than reported previously, while the life expectancy for the asymptomatic patients seems no better than for the symptomatic group.

Survival after liver transplantation of patients with primary biliary cirrhosis in the Nordic countries. Comparison with expected survival in another series of transplantations and in an international trial of medical treatment

Until December 1988, 38 patients with primary biliary cirrhosis (PBC) had been transplanted in the Nordic countries. The observed survival probability in accordance with Kaplan-Meier analysis was around 75% 2-3 months after surgery, with few deaths during the next 3 years. The observed survival curve was compared with the expected survival calculated from the experience of a recent English PBC transplant series; the patterns are very similar. Secondly, the observed survival was compared with the expected survival curve, calculated from the survival experience of an international trial of medical treatment--that is, the expected survival had the patients not been transplanted; after the first 2-3 months the observed survival stayed better than the expected survival. Finally, the merits of transplantation for each particular patient was evaluated by means of the ratio of probability of survival when transplanted to probability of survival when medically treated 3, 6, and 8 months after surgery. The ratio increased with time, indicating a relative increase in the benefit of transplantation with time after surgery.

Secondary biliary cirrhosis. A limiting factor in the treatment of hepatolithiasis

To investigate whether the coexistence of secondary biliary cirrhosis plays a limiting role in the treatment of hepatolithiasis, we retrospectively compared the clinical course and results of stone treatment in 30 patients with secondary biliary cirrhosis (8 in Child's class A and 22 in Child's class B) (group 1) and 240 patients with noncirrhotic biliary calculi (group 2). The hospital mortality, morbidity of treatment, mortality of treatment, and the percentage of treatment failure in group 1 were 20%, 40%, 6.7%, and 16.7%, respectively. Those in group 2 were 8%, 10%, 3.8%, and 10%, respectively. The modes of treatment for stone removal included surgery with postoperative cholangioscopy and percutaneous transhepatic cholangioscopy. There was a statistically significant difference between these two groups in the hospital mortality and the morbidity of treatment. We conclude that hepatolithiasis and biliary stricture should be treated early, before the development of secondary biliary cirrhosis. However, even after cirrhosis occurs, aggressive treatment does not increase the mortality of treatment or the treatment failure rate.

Extramural cross-validation of the Mayo primary biliary cirrhosis survival model establishes its generalizability

The generalizability of the Mayo model for predicting survival in individual primary biliary cirrhosis patients without liver transplantation was tested and confirmed. The model was applied to a data base of patients from the New England Medical Center Hospitals (n = 141) and the Scott and White Clinic (n = 35) and found to predict their survival accurately. It was also shown to be accurate for Mayo primary biliary cirrhosis patients with very advanced disease (n = 30), those with less than a 33% chance of surviving 12 months. The analyses confirmed that the addition of histologic stage did not significantly improve the predictive power of the model (p greater than 0.10). We suggest that the Mayo model is a practical tool for clinical management and decision making.

Significant bacteriuria has prognostic significance in primary biliary cirrhosis

Significant bacteriuria in women has been found to be associated with increased mortality in community-based studies. We have previously reported a high prevalence of significant bacteriuria with a high recurrence rate in females with primary biliary cirrhosis (PBC), particularly those with late stage disease on liver biopsy. During a 5-year period we prospectively screened for significant bacteriuria in 187 women with primary biliary cirrhosis, (median follow-up of 47 months, range 1-83). Significant bacteriuria was found in 30 (17%) in their first urine (index bacteriuria), 90 (48%) died and 15 (8%) had liver transplants. Cox's proportional hazard models showed that age, serum bilirubin, ascites and cirrhosis were independent prognostic variables. Index bacteriuria added significantly to this model (P = 0.069) being independent from other variables, with an increased relative hazard for death of 1.65 (65% increase in risk of death) compared to non-bacteriuric patients. This effect was due mainly to non-cirrhotic patients with significant bacteriuria as shown by using multiplicative variables for histological stage and significant bacteriuria. An index of recurrent bacteriuria was significantly increased in patients with index bacteriuria (P less than 0.001) and in those who died or underwent transplantation (P less than 0.001). In this study, significant bacteriuria defined a specific sub-group of PBC patients with an increased risk of death.

Risk factors and prognosis in primary biliary cirrhosis

The relationship between survival and 25 clinical and histologic variables was studied in 195 patients (171 women, 24 men) who satisfied stringent criteria for the diagnosis of primary biliary cirrhosis. The mean duration of follow-up was 6 yr (range 0-17). One hundred and sixteen patients died, 84% as the result of liver disease and 16% from nonhepatic causes. Using the Kaplan-Meier estimate, we calculated the mortality from liver disease to be 40% after 5 yr and 60% after 10 yr. Ascites, serum bilirubin level, variceal hemorrhage, and age were identified as independent clinical risk factors, and extent of hepatic fibrosis, bilirubinostasis, and Mallory's hyalin were identified as independent histologic risk factors correlating with reduced survival.

Prognosis in primary biliary cirrhosis: model for decision making

The ideal mathematical model for predicting survival for individual patients with primary biliary cirrhosis should be based on a small number of inexpensive, noninvasive measurements that are universally available. Such a model would be useful in medical management by aiding in the selection of patients for and timing of orthotopic liver transplantation. This paper describes the development, testing and use of a mathematical model for predicting survival. The Cox regression method and comprehensive data from 312 Mayo Clinic patients with primary biliary cirrhosis were used to derive a model based on patient's age, total serum bilirubin and serum albumin concentrations, prothrombin time and severity of edema. When cross-validated on an independent set of 106 Mayo Clinic primary biliary cirrhosis patients, the model predicted survival accurately. Our model was found to be comparable in quality to two other primary biliary cirrhosis survival models reported in the literature and to have the advantage of not requiring liver biopsy.

Bootstrap investigation of the stability of a Cox regression model

We describe a bootstrap investigation of the stability of a Cox proportional hazards regression model resulting from the analysis of a clinical trial of azathioprine versus placebo in patients with primary biliary cirrhosis. We have considered stability to refer both to the choice of variables included in the model and, more importantly, to the predictive ability of the model. In stepwise Cox regression analyses of 100 bootstrap samples using 17 candidate variables, the most frequently selected variables were those selected in the original analysis, and no other important variable was identified. Thus there was no reason to doubt the model obtained in the original analysis. For each patient in the trial, bootstrap confidence intervals were constructed for the estimated probability of surviving two years. It is shown graphically that these intervals are markedly wider than those obtained from the original model.

Efficacy of liver transplantation in patients with primary biliary cirrhosis

No controlled trials have been performed to assess the efficacy of liver transplantation. Because of the marked improvement in survival after liver transplantation since 1981, random assignment of patients to a control group not undergoing transplantation is considered clinically inappropriate. To assess the efficacy of liver transplantation in patients with primary biliary cirrhosis, we compared survival in 161 patients with this diagnosis who had undergone a liver transplantation with survival in patients with the same diagnosis who had been treated conservatively. The comparison was performed with use of a recently developed statistical technique, the Mayo model. All patients had undergone liver transplantation between March 1980 and June 1987 and were followed for a median of 25 months. Three months after liver transplantation, the Kaplan-Meier survival probabilities in the recipients were substantially higher than the Mayo-model "simulated-control" survival probabilities (P less than 0.001). At two years, the Kaplan-Meier survival probability was 0.74, whereas the mean Mayo-model survival probability was 0.31. The patients who were at low risk according to the Mayo model had the best probability of survival after liver transplantation; however, patients at all risk levels who had undergone liver transplantation had higher probabilities of survival that those who had not. We conclude that liver transplantation is an efficacious treatment in patients with advanced primary biliary cirrhosis.