Noninvasive Tests for Prognosticating Outcomes in Patients With Chronic Liver Disease in Pregnancy: Ready for Prime Time?

Liver damage parameters and peripheral blood parameters for prediction and diagnosis of intrahepatic cholestasis in pregnancy

OBJECTIVE

Intrahepatic cholestasis of pregnancy (ICP) manifests in late pregnancy. Elevated serum bile acid is a diagnostic criterion: however, its measurement is troublesome. Prediction of ICP by blood markers is not established. Serum bile acid level is associated with liver damage and inflammation. We hypothesized that the following markers could predict the occurrence of ICP and have diagnostic value for it: Liver damage-indicating scores (albumin-bilirubin [ALBI], Model for End-Stage Liver Disease [MELD], aspartate aminotransferase-to-platelet ratio [APRI]) and inflammatory markers (platelet-to-lymphocyte ratio [PLR] and neutrophil-to-lymphocyte ratio [NLR]).

METHODS

Eighty ICP patients and 200 controls were studied. The values of MELD, APRI, ALBI, PLR, and NLR were measured in the 1st trimester and at the time of diagnosis.

RESULTS

Patients with ICP had significantly higher ALBI, MELD, and APRI scores both in the first trimester and at diagnosis. Multivariate logistic regression (MLR) showed that age, ALBI, MELD, and APRI scores were statistically significant (p < 0.05). By receiver operating characteristic (ROC) analysis, the sensitivity of MELD, ALBI, APRI, and NLR in the first trimester was 62%, 73%, 58%, and 29%, respectively, and MELD, ALBI, APRI, and PLR at diagnosis was 28%, 38%, 57%, and 8%, respectively, with a fixed false-positive rate of 10%.

CONCLUSION

This study has demonstrated the usability of the MELD, ALBI, and APRI scores in predicting and diagnosing ICP. They are easy to obtain and might be used in routine practice.

Prevalence of elevated alanine aminotransferase (ALT) in pregnancy: A cross-sectional labor and delivery-based assessment

Since liver tests are not routinely checked in pregnancy, the prevalence of abnormal liver tests and liver-related abnormalities in pregnancy in a US-based population is not known. We sought to determine the prevalence of abnormal alanine aminotransferase (ALT) among pregnant Individuals who present to labor and delivery for evaluation and to evaluate prevalence of underlying diagnosed liver conditions. Prospective study evaluating liver tests in consecutive samples obtained on the labor and delivery unit. Patient characteristics were compared between those with and without abnormal ALT and those with and without abnormal ALT without a liver-related diagnosis made in clinical practice, using t tests for continuous measures and χ2 or Fisher's exact tests as appropriate for categorical measures. Logistic regression was utilized to identify factors associated with abnormal ALT in this subcohort to determine predictors of abnormal ALT in those without a known liver-related diagnosis. We collected 1024 laboratory specimens from 996 patients. Of these patients, 131 of 996 (13.2%) had elevated ALT ≥25 IU/L; 20 (2%) had ALT ≥50, 6 (0.6%) had ALT ≥125 and 3 (0.3%) had ALT ≥250. 61/131 (46.6%) of patients with ALT ≥25 IU/L had not had LTs checked during routine pregnancy care. 20 (15%) of individuals with abnormal LT had preeclampsia; 5 (4%) had cholestasis of pregnancy; 1 (0.8%) had hepatitis C; there were no other chronic liver diseases diagnosed. There were no significant demographic or clinical differences between those with and without ALT ≥25, whether liver disease diagnosis was made or not. We identified an over 10% prevalence of abnormal LTs in consecutive pregnant individuals who presented to L&D, most of whom did not have a liver-related condition diagnosed in clinical practice. Among those with liver-related diagnoses, PE and ICP were the most common among individuals with ALT≥25 IU/mL, with chronic liver disease rarely diagnosed. Further evaluation of the role of ALT testing as part of routine prenatal care is needed, particularly in establishing a baseline prevalence of liver test abnormalities in pregnancy and independent association with pregnancy outcomes.

First-trimester aspartate aminotransferase to platelet ratio index in predicting intrahepatic cholestasis in pregnancy and its relationship with bile acids: A pilot study

OBJECTIVE

To evaluate the predictive value of the first-trimester aspartate aminotransferase (AST)/platelet count ratio [AST to platelet ratio index (APRI) score] for intrahepatic cholestasis in pregnancy (ICP).

METHODS

This study consisted of a patient group diagnosed with ICP (n = 37) and a control group (n = 66) who presented to the hospital perinatology clinic between 2018 and 2020. Laboratory tests of both groups were analysed retrospectively. Age, gravida, parity, body mass index, third-trimester laboratory tests and first-trimester APRI scores were compared between the two groups. A receiver operating characteristic (ROC) analysis of the study was performed to determine the cut-off value for APRI score that is predictive of ICP.

RESULTS

Patients with ICP had significantly higher first-trimester APRI scores compared with controls (p < 0.001). In the ROC analysis, the cut-off value for APRI score was 0.57, with 86.5 % sensitivity and 77.3 % specificity. Spearman's correlation indicated that there was a significant positive association between first-trimester APRI score and third-trimester fasting bile acid level (r = 0.641, p < 0.001). The demographic characteristics of patients in the third trimester did not differ, except for AST and alanine transferase values.

CONCLUSIONS

The APRI score calculated in the first trimester of pregnancy seems to be predictive of the development of ICP in the third trimester.

Fatty liver in pregnancy: a narrative review of two distinct conditions

Introduction: Fatty liver is rather common in pregnancy, occurring in two totally different conditions, i.e. nonalcoholic fatty liver disease (NAFLD) in pregnancy and acute fatty liver of pregnancy (AFLP). The former is a common condition, resulting by chance association because of the epidemics of obesity and the older age of many pregnant women in Western countries; the latter is a rare disease whose pathophysiology is still incompletely understood.Areas covered: We reviewed the evidence-based knowledge on fatty liver in/of pregnancy. For NAFLD, a few large retrospective and prospective studies identify immediate and late risks for both the mother and the fetus. For AFLP, only small retrospective studies are available, indicating that prompt delivery and eventual referral to Liver Units for liver support or transplantation are mandatory to avoid maternal and fetal death.Expert opinion: The number of pregnant women with fatty liver is expected to increase in the next years. Pharmacologic treatment of NAFLD might be postponed, even when new drugs are approved by health authorities for the general population. In the case of AFLP, we need to improve our ability to correctly identify and treat the most severe cases not resolving with delivery.