Rushakoff Joshua A, Cao Louie, Ebinger Joe, Kuo Alexander, Botting Patrick, Emerson Dominic, Countance Guillame, Lebray Pascal, Tompkins Rose, Kobashigawa Jon A, Patel Jignesh K, Guindi Maha, Kransdorf Evan P
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Duke University Medical Center, Durham, North Carolina.
JHLT Open. 2023 Dec 18;4:100045. doi: 10.1016/j.jhlto.2023.100045. eCollection 2024 May.
While abnormalities of liver function and imaging are common in patients with end-stage heart failure, advanced fibrosis is uncommon. Liver biopsy (LB) is used to identify advanced fibrosis in heart transplant (HT) candidates but can delay or limit access to definitive therapies and cause complications. We sought to develop and determine the utility of a clinical risk score for advanced fibrosis in HT candidates.
We conducted a retrospective, single-center review of patients evaluated for HT between 2012 and 2019 ( = 1,651) and identified those who underwent LB ( = 137) as well as a matched control cohort ( = 160). Patients with congenital heart disease were excluded. All biopsies were reviewed by a liver pathologist. Univariate logistic modeling was used to identify factors predictive of advanced liver fibrosis. Simulation using synthetic data bootstraps was performed to determine the utility of using a score-based approach to trigger LB. Kaplan-Meier curves were used to assess survival.
We identified 32 (23%) patients with stage 0, 79 (58%) with stage 1 to 2, and 26 (19%) with stage 3 to 4/advanced fibrosis. The factor most associated with pursuit of LB was abnormal liver parenchyma on ultrasound. We found that a score combining severe tricuspid regurgitation, alcohol use, and low-density lipoprotein improved specificity and reduced the number of LBs required. We found no difference in survival at 3 years post-HT based on pre-HT fibrosis stage.
A score composed of noninvasive factors may help reduce the number of patients who require LB for diagnosis of advanced fibrosis. Additional multicenter studies are needed to validate this score.
虽然肝功能异常和影像学异常在终末期心力衰竭患者中很常见，但晚期纤维化并不常见。肝活检（LB）用于确定心脏移植（HT）候选者的晚期纤维化，但可能会延迟或限制获得确定性治疗的机会并引发并发症。我们试图开发并确定一种针对HT候选者晚期纤维化的临床风险评分的效用。
我们对2012年至2019年间接受HT评估的患者（n = 1651）进行了一项回顾性单中心研究，确定了接受LB的患者（n = 137）以及一个匹配的对照队列（n = 160）。排除先天性心脏病患者。所有活检均由肝脏病理学家进行审查。采用单因素逻辑回归模型来识别预测晚期肝纤维化的因素。使用合成数据自抽样进行模拟，以确定使用基于评分的方法触发LB的效用。采用Kaplan-Meier曲线评估生存率。
我们确定32例（23%）患者为0期，79例（58%）为1至2期，26例（19%）为3至4期/晚期纤维化。与进行LB最相关的因素是超声显示肝实质异常。我们发现，将严重三尖瓣反流、饮酒和低密度脂蛋白相结合的评分提高了特异性，并减少了所需的LB数量。我们发现基于HT前纤维化阶段，HT后3年的生存率没有差异。
由非侵入性因素组成的评分可能有助于减少需要进行LB以诊断晚期纤维化的患者数量。需要更多的多中心研究来验证该评分。
