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Martini F, Balducci D, Mancinelli M, Buzzanca V, Fracchia E, Tarantino G, Benedetti A, Marzioni M, Maroni L. Risk Stratification in Primary Biliary Cholangitis. J Clin Med 2023; 12:5713. [PMID: 37685780 PMCID: PMC10488776 DOI: 10.3390/jcm12175713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Primary Biliary Cholangitis (PBC) is a chronic cholestatic liver disease with a heterogeneous presentation, symptomatology, disease progression, and response to therapy. The current risk stratification assessment, aimed at identifying patients with a higher risk of disease progression, encompasses an in-depth analysis of demographic data, clinical and laboratory findings, antibody profiles, and the evaluation of liver fibrosis using both invasive and noninvasive techniques. Treatment response scores after one year of therapy remain to date a major factor influencing the prognosis of PBC patients. While the initial therapeutic approach with ursodeoxycholic acid (UDCA) is universally applied, new second-line treatment options have recently emerged, with many others under investigation. Consequently, the prevailing one-size-fits-all approach is poised to be supplanted by tailored strategies, ensuring high-risk patients receive the most appropriate treatment regimen from diagnosis. This will require the development of a risk prediction model to assess, at the time of diagnosis, the course, outcome, and response to first and additional treatments of PBC patients. This manuscript provides a comprehensive overview of the current and emerging tools used for risk stratification in PBC and speculates on how these developments might shape the disease landscape in the near future.
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Affiliation(s)
- Francesco Martini
- Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy; (D.B.); (M.M.); (V.B.); (E.F.); (G.T.); (A.B.); (M.M.); (L.M.)
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Cortez-Pinto H, Liberal R, Lopes S, Machado MV, Carvalho J, Dias T, Santos A, Agostinho C, Figueiredo P, Loureiro R, Martins A, Alexandrino G, Cotrim I, Leal C, Presa J, Mesquita M, Nunes J, Gouveia C, Vale AHE, Alves AL, Coelho M, Maia L, Pedroto I, Banhudo A, Pinto JS, Gomes MV, Oliveira J, Andreozzi V, Calinas F. Predictors for incomplete response to ursodeoxycholic acid in primary biliary cholangitis. Data from a national registry of liver disease. United European Gastroenterol J 2021; 9:699-706. [PMID: 34102008 PMCID: PMC8280809 DOI: 10.1002/ueg2.12095] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/28/2021] [Indexed: 12/11/2022] Open
Abstract
Background The current standard of treatment in primary biliary cholangitis (PBC) is ursodeoxycholic acid (UDCA), although a considerable proportion of patients show incomplete response resulting in disease progression. Objective This study aimed to assess the prevalence of incomplete response to UDCA and determine associated patients' characteristics. Methods Patients with PBC as main diagnosis were included from a national multicentric patient registry—Liver.pt. Main endpoints included incomplete response to UDCA treatment according to Barcelona, Paris I and Paris II criteria, Globe and UK PBC scores and the association between baseline characteristics and incomplete response according to Paris II criteria. Results A total of 434 PBC patients were identified, with a mean age of 55 years and 89.2% females. Nearly half of patients were asymptomatic at diagnosis and 93.2% had positive anti‐mitochondrial antibodies. Almost all patients (95.6%) had been prescribed at least one drug for PBC treatment. At the last follow‐up visit, 93.3% were under treatment of which 99.8% received UDCA. Incomplete response to UDCA was observed in 30.7%, 35.3%, 53.7% and 36.4% of patients according to Barcelona, Paris I, Paris II criteria and Globe score, respectively. After adjusting for age and sex, and accordingly to Paris II criteria, the risk for incomplete biochemical response was 25% higher for patients with cirrhosis at diagnosis (odds ratio [OR] = 1.25; 95% confidence interval [95%CI]: 1.02–1.54; p = 0.033) and 35% (95%CI:1.06–1.72; p = 0.016) and 5% (OR = 1.05; 95%CI:1.01–1.10; p = 0.013) for those with elevated gamma‐glutamyl transferase (GGT) and alkaline phosphatase (ALP). Conclusion A considerable proportion of patients showed incomplete biochemical response to UDCA treatment according to Paris II criteria. Cirrhosis, elevated GGT and ALP at diagnosis were identified as associated risk factors for incomplete response. Early identification of patients at risk of incomplete response could improve treatment care and guide clinical decision to a more careful patient monitorization.
Summarise the established knowledge on this subject
Primary biliary cholangitis is a liver disease that can progress to end‐stage liver disease, with premature death or need for liver transplantation. Treatment with ursodeoxycholic acid (UDCA) significantly increases liver transplant‐free survival. However, incomplete response to UDCA reduces this beneficial effect.
What are the significant and/or new findings of this study?
By evaluating prevalence and risk factors for UDCA incomplete response through a large multicentric national registry it was found that 53.7% of patients were incomplete responders, according to Paris II criteria, with cirrhosis, elevated gamma‐glutamyl transferase and alkaline phosphatase at diagnosis as the main risk factors. These findings suggest that patients diagnosed at an advanced stage should be closely monitored and might benefit from novel therapies to improve outcomes if incomplete response is present.
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Affiliation(s)
- Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Departamento de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mariana V Machado
- Clínica Universitária de Gastrenterologia, Departamento de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.,Gastroenterology Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
| | - Joana Carvalho
- Clínica Universitária de Gastrenterologia, Departamento de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Teresa Dias
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Arsénio Santos
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cláudia Agostinho
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Figueiredo
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rafaela Loureiro
- Gastroenterology Department, Central Lisbon Hospital Centre, Lisboa, Portugal
| | - Alexandra Martins
- Gastroenterology Department, Hospital Prof. Doutor Fernando da Fonseca, Lisboa, Portugal
| | - Gonçalo Alexandrino
- Gastroenterology Department, Hospital Prof. Doutor Fernando da Fonseca, Lisboa, Portugal
| | - Isabel Cotrim
- Gastroenterology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Carina Leal
- Gastroenterology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - José Presa
- Internal Medicine Department, Liver Unit, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Mónica Mesquita
- Internal Medicine Department, Liver Unit, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Joana Nunes
- Gastroenterology Department, Hospital Beatriz Ângelo, Lisboa, Portugal
| | - Catarina Gouveia
- Gastroenterology Department, Hospital Beatriz Ângelo, Lisboa, Portugal
| | | | - Ana Luísa Alves
- Gastroenterology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Mariana Coelho
- Gastroenterology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Luís Maia
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Isabel Pedroto
- Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - António Banhudo
- Gastroenterology Department, Unidade Local de Saúde Castelo Branco, Castelo Branco, Portugal
| | - João Sebastião Pinto
- Gastroenterology Department, Unidade Local de Saúde Castelo Branco, Castelo Branco, Portugal
| | | | | | | | - Filipe Calinas
- Gastroenterology Department, Central Lisbon Hospital Centre, Lisboa, Portugal
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