Mathurin Philippe, Abdelnour Marcelle, Ramond Marie-José, Carbonell Nicolas, Fartoux Laetitia, Serfaty Lawrence, Valla Dominique, Poupon Raoul, Chaput Jean-Claude, Naveau Sylvie
Sce d'Hépato-Gastroentérologie, Hôpital Claude Hurriez, and Inserm EPI 0114 Lille, Paris, France.
Hepatology. 2003 Dec;38(6):1363-9. doi: 10.1016/j.hep.2003.09.038.
Early identification of patients with severe (discriminant function >or=32) biopsy-proven alcoholic hepatitis (AH) who are not responding to corticosteroids would be clinically relevant. Our goal was to develop simple criteria that will help physicians to promptly identify nonresponders to corticosteroids. A total of 238 patients were included. We used 6 months survival as an end point because of the rule requiring 6 months for listing alcoholic patients for transplantation. Overall survival at 1 and 6 months was 85% +/- 2.3% and 64.3% +/- 3.3%, respectively. An early change in bilirubin levels (ECBL) at 7 days (defined as bilirubin level at 7 days lower than bilirubin level on the first day of treatment) was observed in 73% of patients. At 7 days, in patients with ECBL, bilirubin decreased (84 +/- 75 micromol/L [4.94 +/- 4.40 mg/dL]), whereas it increased in patients without ECBL (76.5 +/- 77 micromol/L [4.50 +/- 4.54 mg/dL], P <.0001). Ninety-five percent of patients with ECBL continued to have improved liver function during treatment. At 6 months, survival of patients with ECBL was significantly higher than that of patients without ECBL, 82.8% +/- 3.3% versus 23% +/- 5.8%, P <.0001. On multivariate analysis, ECBL, discriminant function and creatinine were independent prognostic variables, and ECBL had the most important prognostic value. In conclusion, ECBL is a very simple predictive factor for identifying nonresponders. A recommendation to discontinue corticosteroids after 7 days in patients without ECBL, suggested by our results, awaits additional confirmation.
早期识别那些活检证实为重度（判别函数≥32）酒精性肝炎（AH）且对皮质类固醇无反应的患者具有临床意义。我们的目标是制定简单的标准，以帮助医生迅速识别对皮质类固醇无反应者。共纳入238例患者。由于将酒精性肝病患者列入移植名单需要6个月的规定，我们将6个月生存率作为终点。1个月和6个月时的总生存率分别为85%±2.3%和64.3%±3.3%。73%的患者在7天时出现胆红素水平早期变化（ECBL，定义为7天时的胆红素水平低于治疗第一天的胆红素水平）。在7天时，有ECBL的患者胆红素下降（84±75微摩尔/升[4.94±4.40毫克/分升]），而无ECBL的患者胆红素升高（76.5±77微摩尔/升[4.50±4.54毫克/分升]，P<0.0001）。95%有ECBL的患者在治疗期间肝功能持续改善。6个月时，有ECBL的患者生存率显著高于无ECBL的患者，分别为82.8%±3.3%和23%±5.8%，P<0.0001。多因素分析显示，ECBL、判别函数和肌酐是独立的预后变量，且ECBL具有最重要的预后价值。总之，ECBL是识别无反应者的一个非常简单的预测因素。我们的结果提示，对于无ECBL的患者，建议在7天后停用皮质类固醇，但这有待进一步证实。
