Characterization of Hypomagnesemia in Alcoholic Hepatitis Patients and Its Association with Liver Injury and Severity Markers

INTRODUCTION

Hypomagnesemia has been documented in alcohol-associated liver disease (ALD). This study aims to characterize hypomagnesemia in alcoholic hepatitis (AH) patients and identify its response with liver injury and severity markers.

MATERIALS AND METHODS

A total of 49 male and female AH patients with an age range of 27-66 years were enrolled in this study. Patients were grouped by MELD: MiAH (mild AH < 12 [n = 5]), MoAH (12 ≤ moderate AH ≤ 19 [n = 13]), and SAH (severe AH ≥ 20 [n = 31]). Patients were also evaluated by MELD grouping as non-severe (MELD ≤ 19 [n = 18]) and severe (MELD ≥ 20 [n = 31]). Data were collected on demographics (Age; BMI), drinking history (AUDIT; LTDH), liver injury (ALT; AST), and liver severity (Maddrey's DF; MELD; AST:ALT). Serum magnesium (SMg) levels were tested as SOC lab (normal ≥ 0.85 ≤ 1.10 mmol/L).

RESULTS

SMg was deficient in each group; the lowest in the MoAH patients. The true positivity of SMg values were at a good performance level when compared between severe and non-severe AH patients (AUROC: 0.695, p = 0.034). We found that the SMg level < 0.78 mmol/L could predict severe AH (sensitivity = 0.100 and 1-specificity = 0.000) at this true positivity, and subsequently analyzed patients with SMg < 0.78 mmol/L (Gr.4) and ≥0.78 mmol/L (Gr.5). Between Gr.4 and Gr.5, there were clinically as well as statistically significant differences in disease severity as defined by MELD, Maddrey's DF, and ABIC scores.

CONCLUSIONS

This study demonstrates the utility of SMg levels to identify AH patients who may have progressed to severe status. The extent of magnesium response in AH patients also corresponded significantly with the prognosis of liver disease. Physicians suspecting AH in patients with recent heavy drinking may use SMg as an indicator to guide further testing, referrals, or treatment.

Endpoints and patient stratification in clinical trials for alcoholic hepatitis

In some areas of medicine the clinical development pathway through phase II and III clinical trials has been well mapped out and refined through extensive experience. In contrast, a number of key questions remain unanswered in the development of novel therapeutics for alcoholic hepatitis. The use of mortality as an endpoint in phase II clinical trials will potentially restrict the appeal of this therapeutic area for pharmaceutical companies, as the number of patients required for adequately powered clinical trials becomes impractical. Herein, we discuss alternative endpoints and conclude that dynamic assessment of liver function is the most pragmatic option in early stage studies. Stratification based on disease severity should be applied to avoid uneven distribution of patients with substantially differing mortality risks. Consensus on early phase trial design would help to facilitate new therapeutic development in this area of high unmet medical need.

Application of prognostic scores in the STOPAH trial: Discriminant function is no longer the optimal scoring system in alcoholic hepatitis

BACKGROUND & AIMS

'Static' prognostic models in alcoholic hepatitis, using data from a single time point, include the discriminant function (DF), Glasgow alcoholic hepatitis score (GAHS), the age, serum bilirubin, international normalized ratio and serum creatinine (ABIC) score and the model of end-stage liver disease (MELD). 'Dynamic' scores, incorporating evolution of bilirubin at seven days, include the Lille score. The aim of this study was to assess these scores' performance in patients from the STOPAH trial.

METHODS

Predictive performance of scores was assessed by area under the receiver operating curve (AUC). The effect of different therapeutic strategies upon survival was assessed by Kaplan-Meier analysis and tested using the log-rank test.

RESULTS

A total of 1,068 patients were studied. The AUCs for the DF were significantly lower than for MELD, ABIC and GAHS for both 28- and 90-day outcomes: 90-day values were 0.670, 0.704, 0.726 and 0.713, respectively. 'Dynamic' scores and change in 'static' scores by Day 7 had similar AUCs. Patients with consistently low 'static' scores had low 28-day mortalities that were not improved with prednisolone (MELD <25: 8.6%; ABIC <6.71: 6.6%; GAHS <9: 5.9%). In patients with high 'static' scores without gastrointestinal bleeding or sepsis, prednisolone reduced 28-day mortality (MELD: 22.2% vs. 28.9%, p = 0.13; ABIC 14.6% vs. 21%, p = 0.02; GAHS 21% vs. 29.3%, p = 0.04). Overall mortality from treating all patients with a DF ≥32 and Lille assessment (90-day mortality 26.8%) was greater than combining newer 'static' and 'dynamic' scores (90-day mortality: MELD/Lille 21.8%; ABIC/Lille 23.7%; GAHS/Lille 20.6%).

CONCLUSION

MELD, ABIC and GAHS are superior to the DF in alcoholic hepatitis. Consistently low scores have a favourable outcome not improved with prednisolone. Combined baseline 'static' and Day 7 scores reduce the number of patients exposed to corticosteroids and improve 90-day outcome.

LAY SUMMARY

Alcoholic hepatitis is a life-threatening condition. Several scores exist to determine the outcome of these patients as well as to identify those who may benefit from treatment. This study looked at the performance of existing scores in patients who had been recruited to the largest alcoholic hepatitis clinical trial: STOPAH. 'Static' scores are calculable at the start of assessment. The three newer static scores (ABIC, GAHS and MELD) were shown to be superior to the oldest score (DF). ABIC and GAHS could also identify patients who had a survival benefit 28 days after starting prednisolone treatment. 'Dynamic' scores relate to the change in disease over the first week of treatment. Combination of the 'static' scores 'with the 'dynamic' scores or change in 'static' scores allowed identification of patients who could benefit from prednisolone up to 90 days.

Prognosis and Prognostic Scoring Models for Alcoholic Liver Disease and Acute Alcoholic Hepatitis

Multiple prognostic scoring systems have been developed to predict mortality from acute alcoholic hepatitis. Some systems, such as the modified discriminant function, are specific to alcoholic hepatitis. Others, such as the model for end-stage liver disease, apply to a broad range of liver diseases. Prognostic factors are better at predicting patients who are likely to survive rather than die of this condition at 30 and 90 days. This important shortcoming may be improved by combining scores for better prediction accuracy.

Invasive aspergillosis in patients with severe alcoholic hepatitis

BACKGROUND & AIMS

Severe alcoholic hepatitis (AH) has a poor short-term prognosis. Although infections are frequent complications of AH, the incidence of invasive aspergillosis (IA) and its impact on outcome remain unknown.

METHODS

We prospectively followed 94 biopsy-proven severe AH episodes for 3 months. We retrospectively reviewed our diagnosis of IA based on EORTC/MSG and AspICU criteria, except for host factors.

RESULTS

Fifteen IA (6 proven, 8 probable, and 1 possible) were diagnosed after a median delay of 26 days following diagnosis of AH. The sites of infection were the lungs (n=11) and central nervous system (n=2), while IA was disseminated in 2 cases. Baseline MELD score ≥24 and ICU admission were independent risk factors for IA. Thirteen IA occurred in the context of corticosteroids, and 2 had received no specific treatment for AH. Non-response to corticosteroids at day 7 was not a risk factor for IA, but IA was associated with absence of liver improvement at day 28. Despite antifungal treatment, 3-month transplant-free survival of patients with IA was 0% compared to 53% in those without IA. IA, Lille score ≥0.45, and overt encephalopathy were independent predictors of transplant-free mortality.

CONCLUSIONS

IA is a frequent complication of severe AH and carries a very high risk of mortality. Systematic screening for IA should be recommended in these patients. Further studies are needed to identify high-risk populations requiring antifungal prophylactic treatment.

The presence of hepatitis B core antibody is associated with more advanced liver disease in alcoholic patients with cirrhosis

BACKGROUND

Liver disease is more severe in patients with chronic hepatitis B virus (HBV) infections and alcohol-induced liver injury. Whether the same is true for alcoholic patients with cirrhosis who have recovered from previous HBV infections remains to be determined.

OBJECTIVES

To document the extent of liver disease in alcoholic patients with cirrhosis who test negative for hepatitis B surface antigen (HBsAg) and test positive for antibody to hepatitis B core antigen (anti-HBc).

METHODS

Two hundred fifty-four alcoholic patients with cirrhosis were divided into anti-HBc-positive (N = 171) and anti-HBc-negative (N = 83) cohorts. Demographic, clinical, and biochemical features were retrospectively analyzed. Prognostic scores and the prevalence of patients at high risk for short-term mortality were calculated. Logistic regression was used to identify factors associated with an increased risk for short-term mortality.

RESULTS

Jaundice was more common in the anti-HBc-positive cohort (32.2% vs. 18.1%, p = 0.02). This cohort also had higher serum bilirubin (70.9 vs. 50.4 μM/L, p = 0.03), prothrombin times (15.6 vs. 14.4 s, p = 0.01), MELD scores (8.5 vs. 4.6, p = 0.01), i-MELD scores (28.6 vs. 24.7, p = 0.03), MDF scores (14.2 vs. 6.8, p = 0.02) and ABIC scores (7.2 vs. 6.6, p = 0.01). In addition, anti-HBC-positive patients were more often at high risk for short-term mortality (40.4% vs. 26.5%, p = 0.03). Multivariate analysis identified anti-HBc-positive status (OR: 1.84; 95% CI: 1.10-3.36) and alcohol intake ≥150 g/day (OR: 2.01; 95% CI: 1.10-3.66) as independent risk factors for high risk of mortality.

CONCLUSION

The anti-HBc-positive state is associated with more advanced liver disease in alcoholic patients with cirrhosis. A prospective study including HBV-DNA testing and liver biopsies should be considered to validate and further elucidate these findings.