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To the Editor:

We read with great interest the article by Cammà et al.1 reporting the potential usefulness of insulin resistance (IR) combined with platelet count/spleen diameter ratio as simple, noninvasive, and easy-to-get tests for predicting esophageal varices (EVs) in patients with Child A cirrhosis caused by hepatitis C virus (HCV). We would like to draw attention to similar studies on IR combined with platelet count/spleen diameter ratio in predicting EVs in cirrhosis, not just in Child A HCV cirrhosis.

Platelet count/spleen diameter ratio as a noninvasive diagnosis test for EVs in cirrhosis,2 including HCV cirrhosis,3 has been widely used in clinical practice for many years. The usefulness of IR in cirrhosis is also not surprising, because recent studies have revealed a close relationship between IR and the progression of chronic liver disease,4 including the fibrosis progression of chronic hepatitis C.5 We tested 349 patients with cirrhosis in our center, including Child A (123 patients), Child B (112 patients), and Child C (114 patients). Compared to the study by Cammà, which reported that a low platelet count/spleen diameter ratio (95% confidence interval [CI], 0.996–0.999) and a high homeostasis model assessment of insulin resistance (HOMA-IR) score (95% CI, 1.018–1.649) could be used to predict the presence of EVs, we found a very similar result in our cohort and also confirmed it in another independent cohort. Further, we also found the HOMA-IR score has a positive correlation with a worsening of the hepatic function. The HOMA-IR score in the Child C group (5.13 ± 0.29) is significantly higher than that of the Child B group (3.39 ± 0.33, P < 0.05) and the Child A group (2.66 ± 0.15, P < 0.05). However, multivariate analysis showed that the 95% CI of the two indexes in Child A HCV cirrhosis in our cohort (Platelet count/spleen diameter ratio: 95% CI, 0.989–0.994; HOMA-IR score, 95% CI, 1.125–1.757) are somewhat different than that of the report by Cammà et al. (95% CI, 0.996–0.999 versus 95% CI, 1.018–1.649, respectively).

In summary, our data highlight three points. First, we show that the IR combined with platelet count/spleen diameter ratio could be used as useful markers to predict EVs in cirrhosis, partially concurring with the findings from the study by Cammà et al. Second, compared with the study by Cammà et al., we show the differential 95% CI of IR and platelet count/spleen diameter ratio in the Chinese population. Differences in results between the two studies are likely to derive from ethnic/geographical variations. Third, considering that the reference intervals of the two indexes may be affected by other factors such as age, sex, and ethnicity, further studies on large, multicenter cohorts are needed to search the appropriate reference intervals in differential ethnic/geographical groups.

References

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  • 1
    Cammà C, Petta S, Di Marco V, Bronte F, Ciminnisi S, Licata G, et al. Insulin resistance is a risk factor for esophageal varices in hepatitis C virus cirrhosis. HEPATOLOGY 2009; 49: 195203.
  • 2
    Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut 2003; 52: 12001205.
  • 3
    Testa R, Testa E, Giannini E, Borro P, Milazzo S, Isola L, et al. Noninvasive ratio indexes to evaluate fibrosis staging in chronic hepatitis C: role of platelet count/spleen diameter ratio index. J Intern Med 2006; 260: 142150.
  • 4
    Kaji K, Yoshiji H, Kitade M, Ikenaka Y, Noguchi R, Yoshii J, et al. Impact of insulin resistance on the progression of chronic liver diseases. Int J Mol Med 2008; 22: 801808.
  • 5
    Ryan P, Berenguer J, Michelaud D, Miralles P, Bellón JM, Alvarez E, et al. Insulin resistance is associated with advanced liver fibrosis and high body mass index in HIV/HCV-coinfected patients. J Acquir Immune Defic Syndr 2009; 50: 109110.

Xiaohua Li Ph.D.*, Kaichun Wu Ph.D.*, Daiming Fan Ph.D.*, * Xijing Hospital of Digestive Disease, Fourth Military Medical University, Xi'an, China.