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Rajendran L, Murillo Perez CF, Ivanics T, Claasen MPAW, Hansen BE, Wallace D, Yoon PD, Sapisochin G. Outcomes of liver transplantation in non-alcoholic steatohepatitis (NASH) versus non-NASH associated hepatocellular carcinoma. HPB (Oxford) 2023; 25:556-567. [PMID: 36828740 DOI: 10.1016/j.hpb.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH)-associated hepatocellular carcinoma (HCC) is a rising indication for liver transplantation. This unique population, with multiple comorbidities, has potential for worse post-transplant outcomes. We compared post-transplant survival of NASH and non-NASH HCC patients using a large cohort. METHODS Adults transplanted for HCC between 2008 and 2018, from United Network for Organ Sharing (UNOS) and University Health Network (UHN) databases were divided into two populations: NASH and non-NASH. Recipient characteristics and post-transplant survival were compared. Subgroup analyses were performed within and beyond Milan criteria. RESULTS 2071 of 20,672 (10.0%) patients underwent transplantation for NASH HCC, with annual proportional increase of 1.2%UHN (p = 0.02) and 1.3%UNOS (p < 0.001). The 1-,3-,5-year post-transplant survival were 90.8%, 83.9%, 76.3% NASH HCC versus 91.9%, 82.1%, 74.9% non-NASH HCC (p = 0.94). No survival differences were observed in populations within or beyond Milan. Competing-risk analysis demonstrated no differences in risk for cardiovascular-related death (HR1.24, 95%CI 0.87-1.55, p = 0.16), or HCC recurrence-related death (HR1.21, 95%CI 0.89-1.65, p = 0.23). NASH HCC patients had lower risk of liver-related deaths (HR0.57, 95%CI 0.34-0.98, p = 0.04). DISCUSSION NASH HCC is a rising indication for liver transplantation. Despite demographic differences, no post-transplantation survival differences were observed between NASH and non-NASH HCC. This justifies equivalent organ allocation, irrespective of NASH status.
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Affiliation(s)
- Luckshi Rajendran
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Canada. https://twitter.com/luckseee
| | - Carla F Murillo Perez
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Department of Surgery, Henry Ford Hospital, Detroit, MI, USA; Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden. https://twitter.com/ivanics_t
| | - Marco P A W Claasen
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands. https://twitter.com/claasen_m
| | - Bettina E Hansen
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Toronto Centre for Liver Disease, University Health Network, Toronto, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, United Kingdom
| | - Peter D Yoon
- Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Gonzalo Sapisochin
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada.
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Murillo Perez CF, Ivanics T, Claasen MPAW, Yoon P, Wallace D, Selzner N, Hirschfield GM, Hansen BE, Sapisochin G. Trends in liver transplantation for autoimmune liver diseases: a Canadian study. Can J Surg 2022; 65:E665-E674. [PMID: 36223935 PMCID: PMC9564189 DOI: 10.1503/cjs.012121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background: To our knowledge, no analysis of data from liver transplantation registries exists in Canada. We aimed to describe temporal trends in the number of liver transplantation procedures, patient characteristics and posttransplantation outcomes for autoimmune liver diseases (AILDs) in Canada. Methods: We used administrative data from the Canadian Organ Replacement Register, which contains liver transplantation information from 6 centres in Canada. This study included transplantation information from 5 of the centres, as liver transplantation procedures in children were not included. We included adult (age ≥ 18 yr) patients with a diagnosis of primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH) or overlap syndrome (PBC–AIH or PSC–AIH) who received a liver transplant from 2000 to 2018. Results: Of 5722 primary liver transplantation procedures performed over the study period, 1070 (18.7%) were for an AILD: 489 (45.7%) for PSC, 341 (31.9%) for PBC, 220 (20.6%) for AIH and 20 (1.9%) for overlap syndrome. There was a significant increase in the absolute number of procedures for PSC, with a yearly increase of 0.6 (95% confidence interval 0.1 to 1.2), whereas the absolute number of procedures for PBC and AIH remained stable. The proportion of transplantation procedures decreased for PBC and AIH but remained stable for PSC. Recipient age at transplantation increased over time for males with PBC (median 53 yr in 2000–2005 to 57 yr in 2012–2018, p = 0.03); whereas the median age among patients with AIH decreased, from 53 years in 2000–2005 to 44 years in 2006–2011 (p = 0.03). The Model for Endstage Liver Disease score at the time of transplantation increased over time for all AILDs, particularly AIH (median 16 in 2000–2005 v. 24 in 2012–2018, p < 0.001). There was a trend toward improved survival in the PBC group, with a 5-year survival rate of 81% in 2000–2005 and 90% in 2012–2018 (p = 0.06). Conclusion: Between 2000 and 2018, the absolute number of liver transplantation procedures in Canada increased for PSC but remained stable for PBC and AIH; proportionally, PBC and AIH decreased as indications for transplantation. Posttransplantation survival improved only for the PBC group. An improved understanding of trends and outcomes on a national scale among patients with AILD undergoing liver transplantation can identify disparities and areas for potential health care improvement.
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Affiliation(s)
- Carla F Murillo Perez
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Tommy Ivanics
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Marco P A W Claasen
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Peter Yoon
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - David Wallace
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Nazia Selzner
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Gideon M Hirschfield
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Bettina E Hansen
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
| | - Gonzalo Sapisochin
- From the Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ont. (Murillo Perez, Hirschfield, Hansen); the Multi-Organ Transplant Program, University Health Network, Toronto, Ont. (Ivanics, Claasen, Yoon, Wallace, Selzner, Sapisochin); the Department of Surgery, Henry Ford Hospital, Detroit, Mich. (Ivanics); the Department of Surgical Sciences, Akademiska sjukhuset, Uppsala University, Uppsala, Sweden (Ivanics); the Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands (Claasen); the Department of Surgery, Westmead Hospital, Sydney, Australia (Yoon); the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (Wallace); the Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK (Wallace); and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Hansen)
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Murillo Perez CF, Harms MH, Lindor KD, van Buuren HR, Hirschfield GM, Corpechot C, van der Meer AJ, Feld JJ, Gulamhusein A, Lammers WJ, Ponsioen CY, Carbone M, Mason AL, Mayo MJ, Invernizzi P, Battezzati PM, Floreani A, Lleo A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Thorburn D, Trivedi PJ, Verhelst X, Parés A, Janssen HLA, Hansen BE. Goals of Treatment for Improved Survival in Primary Biliary Cholangitis: Treatment Target Should Be Bilirubin Within the Normal Range and Normalization of Alkaline Phosphatase. Am J Gastroenterol 2020; 115:1066-1074. [PMID: 32618657 DOI: 10.14309/ajg.0000000000000557] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In primary biliary cholangitis (PBC), bilirubin and alkaline phosphatase (ALP) are widely established as independent predictors of prognosis. Current treatment goals do not aim for normalization of surrogate markers because their association with survival has not been defined. METHODS The patient cohort from the GLOBAL PBC Study Group was used, comprising of long-term follow-up data from European and North American centers. Ursodeoxycholic acid-treated and untreated patients with bilirubin levels ≤1 × upper limit of normal (ULN) at baseline or 1 year were included. The association of normal ALP with transplant-free survival was assessed in a subgroup with ALP ≤1.67 × ULN at 1 year. Optimal thresholds of bilirubin and ALP to predict liver transplantation (LT) or death were evaluated. RESULTS There were 2,281 patients included in the time zero cohort and 2,555 patients in the 1-year cohort. The bilirubin threshold with the highest ability to predict LT or death at 1 year was 0.6 × ULN (hazard ratio 2.12, 95% CI 1.69-2.66, P < 0.001). The 10-year survival rates of patients with bilirubin ≤0.6 × ULN and >0.6 × ULN were 91.3% and 79.2%, respectively (P < 0.001). The risk for LT or death was stable below the bilirubin levels of 0.6 × ULN, yet increased beyond this threshold. Ursodeoxycholic acid-induced reduction in bilirubin below this threshold was associated with an 11% improvement in 10-year survival. Furthermore, ALP normalization was optimal, with 10-year survival rates of 93.2% in patients with ALP ≤ 1 × ULN and 86.1% in those with ALP 1.0-1.67 × ULN. DISCUSSION Attaining bilirubin levels ≤0.6 × ULN or normal ALP are associated with the lowest risk for LT or death in patients with PBC. This has important implications for treatment targets.
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maren H Harms
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Centre de Re[Combining Acute Accent]fe[Combining Acute Accent]rence des Maladies Inflammatoires des VoiesBiliaires, Ho[Combining Circumflex Accent]pital Saint-Antoine, Paris, France
| | - Adriaan J van der Meer
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Pier Maria Battezzati
- Department of Health Sciences, Universita[Combining Grave Accent] degli Studi di Milano, Milan, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Humanitas Clinical Research Center IRCSS, Humanitas University, Rozzano (Milan), Italy
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, United Kingdom
| | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Murillo Perez CF, Hirschfield GM, Corpechot C, Floreani A, Mayo MJ, van der Meer A, Ponsioen CY, Lammers WJ, Parés A, Invernizzi P, Carbone M, Maria Battezzati P, Nevens F, Kowdley KV, Thorburn D, Mason AL, Trivedi PJ, Lindor KD, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Janssen HLA, Hansen BE, Gulamhusein A. Fibrosis stage is an independent predictor of outcome in primary biliary cholangitis despite biochemical treatment response. Aliment Pharmacol Ther 2019; 50:1127-1136. [PMID: 31621931 DOI: 10.1111/apt.15533] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/10/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fibrosis stage predicts prognosis in patients with chronic liver disease independent of aetiology, although its precise role in risk stratification in patients with primary biliary cholangitis (PBC) remains undefined. AIM To assess the utility of baseline fibrosis stage in predicting long-term outcomes in the context of biochemical risk stratification METHODS: In a large and globally representative cohort of patients with PBC, liver biopsies performed from 1980 to 2014 were evaluated. The predictive ability of histologic fibrosis stage in addition to treatment response at 1 year (Toronto/Paris-II criteria), as well as non-invasive markers of fibrosis (AST/ALT ratio [AAR], AST to platelet ratio index [APRI], FIB-4), for transplant-free survival was assessed with Cox proportional-hazards models. RESULTS There were 1828 patients with baseline liver biopsy. Advanced histologic fibrosis (stage 3/4) was an independent predictor of survival in addition to non-invasive measures of fibrosis with the hazard ratios ranging from 1.59 to 2.73 (P < .001). Patients with advanced histologic fibrosis stage had worse survival despite biochemical treatment response, with a 10-year survival of 76.0%-86.6% compared to 94.5%-95.1% depending on the treatment response criteria used. Poor correlations were observed between non-invasive measures of fibrosis and histologic fibrosis stage. CONCLUSION Assessment of fibrosis stage grants prognostic value beyond biochemical treatment response at 1 year. This highlights the need to incorporate fibrosis stage in individual risk stratification in patients with PBC, partly to identify those that may derive benefit from novel therapies.
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Cheung AC, Lammers WJ, Murillo Perez CF, van Buuren HR, Gulamhusein A, Trivedi PJ, Lazaridis KN, Ponsioen CY, Floreani A, Hirschfield GM, Corpechot C, Mayo MJ, Invernizzi P, Battezzati PM, Parés A, Nevens F, Thorburn D, Mason AL, Carbone M, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lindor KD, Lleo A, Poupon R, Janssen HLA, Hansen BE. Effects of Age and Sex of Response to Ursodeoxycholic Acid and Transplant-free Survival in Patients With Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2019; 17:2076-2084.e2. [PMID: 30616022 DOI: 10.1016/j.cgh.2018.12.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/07/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) predominantly affects middle-aged women; there are few data on disease phenotypes and outcomes of PBC in men and younger patients. We investigated whether differences in sex and/or age at the start of ursodeoxycholic acid (UDCA) treatment are associated with response to therapy, based on biochemical markers, or differences in transplant-free survival. METHODS We performed a longitudinal retrospective study of 4355 adults in the Global PBC Study cohort, collected from 17 centers across Europe and North America. Patients received a diagnosis of PBC from 1961 through 2014. We evaluated the effects of sex and age on response to UDCA treatment (based on GLOBE score) and transplant-free survival using logistic regression and Cox regression analyses, respectively. RESULTS Male patients were older at the start of treatment (58.3±12.1 years vs 54.3±11.6 years for women; P<.0001) and had higher levels of bilirubin and lower circulating platelet counts (P<.0001). Younger patients (45 years or younger) had increased serum levels of transaminases than older patients (older than 45 years). Patients older than 45 years at time of treatment initiation had increased odds of a biochemical response to UDCA therapy, based on GLOBE score, compared to younger patients. The greatest odds of response to UDCA were observed in patients older than 65 years (odds ratio compared to younger patients 45 years or younger, 5.48; 95% CI, 3.92-7.67; P<.0001). Risk of liver transplant or death (compared to a general population matched for age, sex, and birth year) decreased significantly with advancing age: hazard ratio for patients 35 years or younger, 14.59 (95% CI, 9.66-22.02) vs hazard ratio for patients older than 65 years, 1.39 (95% CI, 1.23-1.57) (P<.0001). On multivariable analysis, sex was not independently associated with response or transplant-free survival. CONCLUSION In longitudinal analysis of 4355 adults in the Global PBC Study, we associated patient age, but not sex, with response to UDCA treatment and transplant-free survival. Younger age at time of treatment initiation is associated with increased risk of treatment failure, liver transplant, and death.
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Affiliation(s)
- Angela C Cheung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Marlyn J Mayo
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Albert Parés
- Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, CIBERehd, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, United Kingdom
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Ana Lleo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Raoul Poupon
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Murillo Perez CF, Goet JC, Lammers WJ, Gulamhusein A, van Buuren HR, Ponsioen CY, Carbone M, Mason A, Corpechot C, Invernizzi P, Mayo MJ, Battezzati PM, Floreani A, Pares A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Thorburn D, Hirschfield G, LaRusso NF, Lindor KD, Zachou K, Poupon R, Trivedi PJ, Verhelst X, Janssen HLA, Hansen BE. Milder disease stage in patients with primary biliary cholangitis over a 44-year period: A changing natural history. Hepatology 2018; 67:1920-1930. [PMID: 29220537 DOI: 10.1002/hep.29717] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/21/2017] [Accepted: 12/02/2017] [Indexed: 01/03/2023]
Abstract
UNLABELLED Changes over time in the presenting features and clinical course of patients with primary biliary cholangitis are poorly described. We sought to describe temporal trends in patient and disease characteristics over a 44-year period across a large international primary biliary cholangitis cohort of 4,805 patients diagnosed between 1970 and 2014, from 17 centers across Europe and North America. Patients were divided into five cohorts according to their year of diagnosis: 1970-1979 (n = 143), 1980-1989 (n = 858), 1990-1999 (n = 1,754), 2000-2009 (n = 1,815), and ≥2010 (n = 235). Age at diagnosis, disease stage, response to ursodeoxycholic acid, and clinical outcomes were compared. Mean age at diagnosis increased incrementally by 2-3 years per decade from 46.9 ± 10.1 years in the 1970s to 57.0 ± 12.1 years from 2010 onward (P < 0.001). The female to male ratio (9:1) and antimitochondrial antibody positivity (90%) were not significantly variable. The proportion of patients presenting with mild biochemical disease (according to Rotterdam staging) increased from 41.3% in the 1970s to 72.2% in the 1990s (P < 0.001) and remained relatively stable thereafter. Patients with a mild histological stage at diagnosis increased from 60.4% (1970-1989) to 76.5% (1990-2014) (P < 0.001). Correspondingly, response to ursodeoxycholic acid according to Paris-I criteria increased; 51.7% in the 1970s and 70.5% in the 1990s (P < 0.001). Recent decades were also characterized by lower decompensation rates (18.5% in the 1970s to 5.8% in the 2000s, P < 0.001) and higher 10-year transplant-free survival (48.4%, 68.7%, 79.7%, and 80.1% for each respective cohort; P < 0.001). CONCLUSION In recent decades, a pattern of primary biliary cholangitis presentation consistent with an older age at diagnosis alongside reduced disease severity has been noted; the observed trends may be explained by an increase in routine testing of liver function and/or a changing environmental trigger. (Hepatology 2018;67:1920-1930).
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Insitute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jorn C Goet
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, TX
| | | | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Gideon Hirschfield
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | | | | | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Palak J Trivedi
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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