识别导致慢加急性肝衰竭的自身免疫性肝炎发作患者对类固醇治疗无应答的早期预测因子。
Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure.
机构信息
Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110026, India.
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
出版信息
Hepatol Int. 2023 Aug;17(4):989-999. doi: 10.1007/s12072-023-10482-4. Epub 2023 Feb 15.
BACKGROUND AND AIMS
Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment.
METHODS
Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90 days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [- 6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2 weeks.
RESULTS
Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0 years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90 day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2 weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3 days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ - 1.2, could identify non-responders at day 3 (concomitant- 75% vs either - 42%, p < 0.001).
CONCLUSION
Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.
背景和目的
在导致慢加急性肝衰竭（ACLF）的自身免疫性肝炎（AIH）患者中，早期识别对类固醇的无应答至关重要。我们评估了在治疗的最初几天内是否可以准确识别这种无应答。
方法
从亚太肝脏研究协会（APASL）ACLF 研究联盟（AARC）数据库中确定了没有基线感染/肝性脑病的 AIH-ACLF 患者。AIH-ACLF 的诊断主要基于组织学。接受类固醇治疗的患者评估其无应答（定义为 90 天内死亡或肝移植）。在基线和第 3 天评估实验室参数、AARC 和终末期肝病模型（MELD）评分，以确定早期无应答。还评估了动态 SURFASA 评分[-6.80+1.92*(D0-INR)+1.94*(∆%3-INR)+1.64*(∆%3-胆红素)]的效用。比较了早期预测因子的性能与 2 周时 MELD 评分的变化。
结果
在 165 例 AIH-ACLF 患者（年龄 38.2±15.0 岁，67.2%为女性）中，有 55 例（中位 MELD 24[IQR：22-27]；中位 AARC 评分 7[6-9]）接受了口服泼尼松龙 40（20-40）mg/天。该队列的 90 天无移植存活率为 45.7%，有新发感染的患者预后更差（56% vs 28.0%，p=0.03）。治疗前 AARC 评分的 AUROC [0.842（95%CI 0.754-0.93）]、MELD [0.837（95%CI 0.733-0.94）]评分和 SURFASA 评分[0.795（95%CI 0.678-0.911）]与 2 周时的∆MELD[0.770（95%CI 0.687-0.845）]一样准确，优于 3 天时的∆MELD[0.541（95%CI 0.395,0.687）]（p<0.001），预测无应答。AARC 评分>6、MELD 评分>24 与 SURFASA 评分≥-1.2 的组合，可在第 3 天识别无应答者（同时 75% vs 任一-42%，p<0.001）。
结论
基线 AARC 评分、MELD 评分和第 3 天的动态 SURFASA 评分可准确识别 AIH-ACLF 患者对类固醇的早期无应答。
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