Prognostic Role of Liver Biopsy in Patients With Severe Indeterminate Acute Hepatitis

Clinical significance of transjugular liver biopsy in acute liver failure - a real-world analysis

BACKGROUND

Histopathological characterization obtained by transjugular liver biopsy (TJLB) may theoretically contribute to clarification of the exact aetiology of acute liver failure (ALF). It's unclear whether the histopathological information from TJLB, due to the small specimen size, significantly contributes to diagnosing ALF causes, guiding therapy decisions, or predicting overall prognosis. This retrospective study aimed to analyse safety and clinical significance of TJLB in patients with ALF.

METHODS

This retrospective, monocentric study investigated safety and efficacy of TJLB in patients with ALF over a ten-year period at a tertiary care transplant-center. The predictive value of various clinical and laboratory characteristics as well as histopathological findings obtained by TJLB on 28-day liver-transplant-free survival were evaluated by calculating uni- and multivariate Cox-proportional hazard regression models. Additional univariate logistic regression analyses were performed to explore the influence of degree of intrahepatic necrosis on the secondary endpoints intensive-care-unit (ICU) admission, need for endotracheal intubation, renal replacement therapy and high-urgency listing for LTX.

RESULTS

A total of 43 patients with ALF receiving TJLB were included into the study. In most cases (n = 39/43 cases) TJLB confirmed the initially already clinically presumed ALF aetiology and the therapeutic approach was unchanged by additional histological examination in the majority of patients (36/43 cases). However, in patients with a high suspicion for aetiologies potentially treatable by medical immunosuppression (e.g. AIH, GvHD), TJLB significantly influenced further treatment planning and/or adjustment. While the degree of intrahepatic necrosis showed significance in the univariate analysis (p = 0.04), it did not demonstrate a significant predictive effect on liver transplant-free survival in the multivariate analysis (p = 0.1). Only consecutive ICU admission was more likely with higher extent of intrahepatic necrosis (Odds ratio (OR) 1.04 (95% CI 1-1.08), p = 0.046).

CONCLUSIONS

Performance of TJLB in ALF led to a change in suspected diagnosis and to a significant change in therapeutic measures only in those patients with a presumed high risk for aetiologies potentially responsive to immunosuppressive therapy. Clinical assessment alone was accurate enough, with additional histopathological examination adding no significant value, to predict overall prognosis of patients with ALF.

Severe acute liver disease in adults: Contemporary role of histopathology

Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).

Fatty liver disease reverses the obesity paradox in chronic kidney disease stages 3-5: A follow-up study of NHANES III

High body mass index (BMI) has been associated with better survival in patients with end-stage kidney disease. Individuals with fatty liver disease (FLD) have a higher risk of chronic kidney disease. It remains unclear whether the survival benefit of high BMI in patients with chronic kidney disease is present when there is concomitant FLD. This study used the data set from the Third American National Health and Nutrition Examination Survey and the corresponding survival data. The Cox proportional hazards model was used to evaluate the effect of BMI on mortality. A total of 12,445 participants were included. The prevalence of FLD was 39.8%. The median follow-up time (with interquartile range) was 22.8 (20.8-24.8) years. During this period, 3749 (30.1%, 14.4 of 1000 person-year) deaths were observed. Among these, 1169 (31.2%) died within the first 10 years. The Cox regression analysis showed that the BMI level was not associated with 25-year mortality in patients with decreased glomerular filtration rate (GFR < 60 ml/min/1.73 m² ), but 10-year mortality was significantly lower in patients with BMI ≥ 25 kg/m² than in those with BMI < 25 kg/m² (p = 0.049). Multivariate analysis showed BMI ≥ 25 kg/m² was an independent protective factor for 10-year mortality (hazard ratio [HR] 0.691, 95% confidence interval [CI] 0.559-0.856; p = 0.001). This protective effect of higher BMI was lost in patients with FLD (HR 0.884, 95% CI 0.585-1.335; p = 0.557) but persisted in the non-FLD group (HR 0.625, 95% CI 0.479-0.816; p = 0.001). The survival benefit of overweight/obesity for patients with decreased GFR, which was attenuated by the presence of FLD, only existed in the first decade.

Presence of multilobular necrosis on liver biopsy identifies corticosteroid responsiveness in acute indeterminate hepatitis

BACKGROUND AND AIMS

Treatment of patients with severe indeterminate hepatitis (IAH) is an unmet need. Corticosteroids are often used in the management of these patients but criteria for the selection of patients for this intervention are arbitrary. The aims of this study were to analyse the clinical and pathological features of patients with IAH to define predictors of corticosteroid responsiveness.

METHODS

This study included consecutive patients with acute indeterminate hepatitis admitted to a single hospital and underwent a liver biopsy. The clinical manifestation and histopathological features of steroid and non-steroid groups were compared and their relationship with corticosteroids response was evaluated.

RESULTS

Forty-eight patients were included, 24 (50%) recovered and the other half underwent liver transplantation or died within 3-months. Of the 48 cases, 24 received corticosteroids (initial dose of 45 ± 12 mg prednisolone). Corticosteroids were initiated 2.7 ± 3.8 days after admission. Liver biopsy was performed 2-days (median, IQR 1-3) after admission. Fifteen (62.5%) patients receiving corticosteroids survived without transplantation compared with 9 (37.5%) that did not receive steroids (P = .149). In those with multilobular necrosis, 50% reduction in the death/transplantation rate was observed after steroid treatment (P = .018). In patients without multilobular necrosis and with or without perivenulitis, corticosteroids did not impact the outcome. Response to corticosteroids was independent of the MELD score.

CONCLUSIONS

The presence of multilobular necrosis on liver biopsy helps identify a subgroup of IAH cases who may benefit from the administration of corticosteroids.