Madrid, 21 Febrero 2018
43 Congreso Anual AEEH
Curso de Postgrado
Salvador Augustin
Medicina Interna - Hepatología
Hospital Universitari Vall d’Hebron
Universitat Autònoma de Barcelona
ENFERMEDAD HEPÁTICA CRÓNICA AVANZADA
(cACLD) Concepto y potenciales ventajas sobre el concepto
de cirrosis
Clinical case
- 55 yo female
- Sent for incidental steatosis at abdominal US
- History: hypertension (losartan 50 mg/d)
- Physical Exam: height 1.54, weight 86 kg (BMI 36.2)
- Blood: AST 34, ALT 24, GGT 129, plat 200.000, Glu 112,
TC 161, TGC 206
- No alcohol, virus -, ANA -, Ferritin 230
Clinical case
-LS 12.3 kPa, IQR 1.0
-CAP 391, IQR 42
-SR 10/11
• Cirrhosis– Importance
– Limitations
• Impact of Fibroscan
• cACLD– Definition
– Association to histology and clinical outcomes
Outline
• PROGNOSIS
– Prophylaxis of variceal bleeding
– Screening HCC
• STUDIES / TRIALS (design, interpretation)
– Diagnostic / prognostic
– Therapeutic
Diagnosis of Cirrhosis – What For?
What patients are at risk of complications?
To this aim, is the concept of cirrhosis useful?
• Invasive
• Sample variability
• Inter-observer variability
• Poor sensitivity for staging
within cirrhosis
Histologic diagnosis of cirrhosis - LIMITATIONS
García-Tsao et al., Hepatology 2010
More than one “cirrhosis”…
Liver (spleen) stiffness
Serumbiomarkers
Imaging
Clinical signs
SIGNOS ROJOS EN V. ESOFAGICAS
Non-invasive diagnosis of cirrhosis
Development of new TOOLS Development of new IDEAS
EV 53%, CSPH 77% EV 63%, CSPH 65%
“Classic” diagnosis of cirrhosis
NORMAL Plt & US ABNORMAL Plt &/or US
N=250 Patients with compensated chronic liver disease
<13.6 kPa >13.6 kPa <13.6 kPa >13.6 kPa
N=290 General Liver ClinicsN=40 Known
CSPH/decomp.
Routine blood tests, abdominal US, LS measurement
Follow-Up Upper Endoscopy + HVPG
2/3 1/3
EV 20%, CSPH 65%
NORMAL Plt & US ABNORMAL Plt &/or US
N=40
N=182 Patients with presumed/confirmed compensated cirrhosis
<13.6 kPa
CSPH9/20=45%
>13.6 kPa
CSPH1/20=5%
N=142
<13.6 kPa
CSPH 90/119=75%
>13.6 kPa
CSPH9/23=39%
132
9
19
LSM <8 kPa LSM 8-10 kPa LSM ≥10 kPa
(82%)
453
LSM <8 kPa LSM 8-10 kPa LSM ≥10 kPa
(94%)
(12%)
(6%) (6%)
Diabetics N=160 Controls N=48
LS>10 kPa: 19/160 (12%)
PRECISED studyAsymptomatic Diabetic Population (Barcelona)
1 HCV+ (LSM 75 kPa)2 OH (LSM 18,8 i 45 kPa)1 HBsAg+ (LSM 10,3 kPa)15 OCCULT NASH: 53% NORMAL ALT & PLAT
?
CLINICAL DIAGNOSI
S
CLINICAL DIAGNOSI
S
TRANSIENTELASTOGRAPH
Y
F0 F1 F2 cACLD-LC
CLINICAL DIAGNOSI
S
LIVER BIOPSY
TRANSIENTELASTOGRAPH
Y
CHRONIC LIVER DISEASE
Impact of elastography - cACLD
Baveno 6 – Defining cACLD
• TE values <10 kPa in the absence of other known clinical signs rule out cACLD
•Values between 10-15 kPa are suggestive of cACLD but need further test for
confirmation
•Values >15 kPa are highly suggestive of cACLD
de Franchis et al., J Hepatol 2015
Tsochatzis, et al. EASL ILC 2017
cACLD - Histology
Stage HCV(n=2609)
NAFLD(n=889)
HBV(n=695)
Total(n=4198)
0 171 (7%) 177 (20%) 83 (12%) 431 (10%)
1 796 (30%) 276 (31%) 246 (35%) 1318 (31%)
2 866 (33%) 192 (22%) 168 (24%) 1226 (29%)
3 431 (17%) 144 (16%) 114 (16%) 689 (16%)
4 345 (13%) 100 (11%) 84 (12%) 529 (13%)
cACLD 1218 (29%)
Meta-analysis individual patients, 8 European centres
Tsochatzis, et al. EASL ILC 2017
F0-F2 cACLD Se Sp PPV NPV LR (+) LR (-)
TE <10 KPa 2587 365 86.8 69.9 68.5 87.6 2.9 0.19
TE >15 KPa 95 485 39.8 96.8 83.6 79.7 12.5 0.6
cACLD - HistologyMeta-analysis individual patients, 8 European centres
• Between 10-15 kPa suggestive of cACLD
• >15 kPa highly suggestive of cACLD
ANTICIPATE STUDY
229 patientsLSM/HVPG
48LS 10-15
181LS ≥15
HVPG>5 mmHg85.5%
CSPH: 29%
HVPG>5 mmHg95.5%
CSPH: 75%
cACLD - Portal Hypertension
Chen T, et al. Liver Int 2015
N=685 (HCV 31%, HBV 25%, NALD 22%, ALD 4%)
cACLD - Outcomes: Decompensation
Park, et al. Expert Rev Gastro Hep 2014
Meta-analysis, N=5085 (mixed etiologies, HBV >60%)
cACLD - Outcomes: risk of HCC
Tatsumi, et al. Hepatol Res 2015
N=1002 (HCV 72%, HBV 10%, Other 18%)
cACLD - Outcomes: risk of HCC
F3 F4
CLINICAL STAGE
EARLY COMPENSATED CIRRHOSIS
DECOMPENSATED CIRRHOSIS
CLD
HISTOLOGY
F4 F4
LATE COMPENSATED CIRRHOSIS
CLINICAL STAGE
DECOMPENSATED CIRRHOSIS
EARLY cACLD
LATEcACLD
ELASTOGRAPHY (kPa)
20-30 (25)
VARICES
10
HVPG (mmHg) 5 10
HCC
>10
Liver Bx: NASH, NAS 7, F4 HVPG: 6 mmHg
LS 12.3 kPa
Gracias!!!
Top Related