Autoimmune, Cholestatic and Biliary Disease
The predictors of the presence of varices in patients with primary sclerosing cholangitis†
Article first published online: 13 NOV 2009
Copyright © 2009 American Association for the Study of Liver Diseases
Volume 51, Issue 4, pages 1302–1310, April 2010
How to Cite
Treeprasertsuk, S., Kowdley, K. V., Luketic, V. A. C., Harrison, M. E., McCashland, T., Befeler, A. S., Harnois, D., Jorgensen, R., Petz, J., Keach, J., Schmoll, J., Hoskin, T., Thapa, P., Enders, F. and Lindor, K. D. (2010), The predictors of the presence of varices in patients with primary sclerosing cholangitis. Hepatology, 51: 1302–1310. doi: 10.1002/hep.23432
Potential conflict of interest: Dr. McCashland is on the speakers' bureau of Roche.
- Issue published online: 26 MAR 2010
- Article first published online: 13 NOV 2009
- Accepted manuscript online: 13 NOV 2009 12:00AM EST
- Manuscript Accepted: 9 NOV 2009
- Manuscript Received: 5 OCT 2009
- National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK 56924)
- Axcan Pharma
- Virginia Commonwealth University from the National Center for Research Resources. Grant Number: M01RR000065
The predictors for developing varices in patients with primary sclerosing cholangitis (PSC) have not been well studied prospectively. We sought to define the predictors for the presence of varices at baseline and for newly developing varices in patients with PSC. We used prospectively collected data from a multicenter randomized trial of high dose ursodeoxycholic acid for PSC. All 150 patients enrolled were reviewed for predictors of varices and we excluded 26 patients who had esophageal varices at baseline so that predictors of newly developing varices could be determined. Clinical examination, blood tests, and upper endoscopy were done before randomization, at 2 years and after 5 years. Liver biopsy was performed at entry and at 5 years. The median age (interquartile range) of patients was 45.9 years (35.8, 54.9). In a multivariable logistic regression, a higher Mayo risk score (≥0.87) or a higher aspartate/alanine aminotransferase (AST/ALT) ratio (≥1.12) were significantly associated with the presence of varices at initial endoscopy (odds ratio = 1.9 and 3.9). By the end of the study, 25 patients had new varices (20.2%). In a Cox model, after adjustment for baseline variables lower platelet count and higher total bilirubin at 2 years were significantly associated with the presence of new varices. The platelet count of 205 (× 109/L) and the total bilirubin level of 1.7 mg/dL were the best cutoff values for the detection of new varices. Conclusion: A higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of varices at initial endoscopy. Lower platelet count and higher total bilirubin at 2 years were significantly associated with an increased risk of developing new varices in patients with PSC. (HEPATOLOGY 2010.)
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown etiology characterized by fibrosing inflammation and destruction of the extrahepatic and/or intrahepatic bile ducts. No effective medical therapy exists for patients with PSC.1 The diseases progresses slowly and usually leads to biliary cirrhosis, portal hypertension, and liver failure over 10-15 years with significantly shorter survival than people of similar age and sex.2 A previous study showed that 36% of patients with PSC had esophageal varices (EV) at the time of their first visit and half of them had moderate or large EV. Noninvasive markers including platelet count, albumin level, and advanced histologic disease were independent predictors of EV.3 The limitation of that study is that 51% of patients had advanced histologic stage at baseline and the Mayo PSC risk score was not shown. Another study showed that clinical predictors, including thrombocytopenia and splenomegaly, could be used to stratify patients with cirrhosis for the risk of large EV.4, 5 A platelet count of less than 88,000/mm3 carried a risk of large EV of 28% whereas a platelet count of less than 68,000/mm3 was used as a cutoff value for large EV with a sensitivity of 71% and a specificity of 73%.4, 5 However, the causes of liver diseases in most patients in these studies were alcohol abuse and viral hepatitis, and the associations were usually made at one point in time.
Liver biopsy may not routinely be necessary for diagnosis of PSC in the absence of atypical findings and is also hampered by sampling variability.6, 7 Moreover, liver biopsy also has several limitations for clinical practice, including the expense and the invasive nature of the procedure which is associated with a number of complications.8, 9 A revised natural history model for PSC risk score from the Mayo Clinic based on patient age, bilirubin levels, albumin, aspartate aminotransferase (AST) levels, and history of variceal bleeding was developed to assess 1-year to 4-year probability of survival of patients with PSC.10 An advantage of the Mayo PSC risk score is that there is no requirement for liver histology.10
The predictors for developing varices in patients with PSC have not been well studied prospectively. Our aims were to evaluate predictors for the presence of varices at baseline and also for developing new varices in patients with PSC.
Patients and Methods
Patients were entered based on the following criteria with exceptions approved by our Institutional Review Boards.
PSC was defined as present when all the following criteria were met: (1) chronic cholestatic disease of at least 6 months duration; (2) serum alkaline phosphatase (ALP) at least 1.5 times the upper limits of normal; (3) retrograde, operative, percutaneous, or magnetic resonance cholangiography demonstrating intrahepatic and/or extrahepatic biliary duct obstruction, beading, or narrowing consistent with PSC within 1 year of the study entry; (4) liver biopsy in the previous 1 year which was available for review and compatible with the diagnosis of PSC (seven patients did not have entry liver biopsy due to low platelet count and/or presence of cirrhosis). Compatible biopsy features included fibrous cholangitis, ductopenia with periportal inflammation, and biliary fibrosis.
Patients were excluded if they had any of the following: (1) coexistent conditions such as pre-existing advanced malignancies or severe cardiopulmonary disease which would limit their life expectancy to less than 2 years; (2) inability to provide consent; (3) treatment with ursodeoxycholic acid (UDCA), pentoxifylline, corticosteroids, cyclosporin, colchicine, azathioprine, methotrexate, D-penicillamine, budesonide, nicotine, pirfenidone, or tacrolimus in the 3 months prior to study entry; (4) patients with inflammatory bowel disease patients requiring specific treatment in the preceding 3 months except for maintenance therapy with a 5-aminosalicylic acid compound; (5) anticipated need for liver transplantation within 2 years (expected survival of <80% at 2 years based on Mayo risk score); (6) history of recurrent variceal bleeds, spontaneous uncontrolled encephalopathy, international normalized ratio > 1.5 uncorrected by vitamin K or resistant ascites that suggested an anticipated survival of less than 1 year; (7) pregnancy or lactation (patients who became pregnant during the study were discontinued and referred to their physicians); (8) age less than 18 years or greater than 75 years; (9) findings highly suggestive of liver disease of other etiology such as chronic alcoholic liver disease, chronic hepatitis B or C infection, autoimmune hepatitis, primary biliary cirrhosis, hemochromatosis, Wilson's disease, congenital biliary disease, or cholangiocarcinoma; (10) previous intraductal stones or operations on the biliary tree, other than cholecystectomy, such as biliary drainage procedures preceding the diagnosis of PSC; (11) recurrent ascending cholangitis requiring hospitalization occurring more than two times per year.
From the 455 patients assessed, 150 patients were entered into the study over a 3-year period from seven sites. Of the 305 patients with PSC (67%) who were screened but not enrolled, 11 were eligible but declined, 141 were not eligible, and 153 had unknown eligibility. The majority of the 141 patients were not eligible due to inadequate ALP elevation and exclusionary medication use; other reasons included advanced liver disease, age, and complicating medical conditions. Eligibility was not known in 153, because these patients declined further testing for reasons including cost, the randomized nature of the trial, concern about side effects, and in the majority, unknown reasons.
Randomization and Stratification
All screened patients found to be eligible and who provided written informed consent to participate in the study were randomized to one of two groups: (1) UDCA at a dose of 28-30 mg/kg/day or (2) an identical-appearing placebo.
The randomization was stratified by histologic stage I or II versus III or IV, presence or absence of varices, and Mayo risk score. Computer-based dynamic allocation was used to assign patients to study groups via the coordinating center in Rochester, MN. Further details regarding the drug administration, patient compliance, and termination were reported elsewhere.11
Mayo risk score at baseline was calculated to obtain survival estimates up to 4 years of follow-up10 and it can be accessed from the Mayo Clinic web site (www.mayoclinic.org/gi-rst/mayomodel3.html). Liver enzymes were assessed by mailed containers or patient visit every 3 months to monitor for possible toxicity and to assess biochemical response. Patients were examined annually. Complete blood counts, prothrombin time, and ultrasound were assessed at baseline and annually. Rate of total bilirubin (TB) or platelet count change per year (%) were calculated by the difference of TB or platelet counts at the second year minus by those at baseline and divided by the TB or platelet counts at baseline by the following formula: % rate change of TB per year = ([TB at year 2 − TB at baseline/TB at baseline]*100)/2.
Upper endoscopy to assess for varices was done at 2 years. The standard classification for EV grading was reported as no varices (F0), small and nontortuous (F1), medium or tortuous but less than 50% radius of esophagus (F2), and large (F3).12 Endoscopic retrograde cholangiography and liver biopsy were scheduled to be repeated at 5 years after entry. Treatment was stopped if liver transplantation was required.
Data was collected prospectively at each clinical center and forwarded to Mayo Clinic Rochester, which served as the coordinating center. The data were entered into computers at the coordinating center once the initial quality assurance audits were completed at the originating study site. Laboratory values such as serum liver biochemistries were normalized by dividing the actual value by the upper limits of normal for the clinical laboratory in which the test was performed.
For the first aim, 150 patients with PSC were analyzed and for the second aim, we excluded 26 patients who had esophageal or gastric varices at baseline, thus 124 patients were included for analysis. Baseline characteristics were calculated as the median (interquartile range [IQR]) for continuous variables, and the number and percent in each group were tabulated for categorical variables.
The patients with PSC with a fibrosis stage of 1-2 were classified as “mild liver fibrosis” and those with a fibrosis stage of 3-4 were classified as “advanced liver fibrosis”.
We assessed the effect of Mayo risk score for predicting the presence of EV at baseline in patients with PSC adjusting for a variety of baseline characteristics. Logistic regression analysis was used to identify the factors significantly associated with advanced liver fibrosis or presence of varices in 150 patients with PSC. Only those variables with a P value < 0.2 by univariate analysis were included in multivariate analysis. In order to avoid overestimation of the model, we excluded those variables used as a part of Mayo Risk Scores calculation. We used a receiver operating characteristic (ROC) of related variables for detection of patients with development of varices with the best area under the curve (AUC). Time to event was time from randomization to first development of varices in 124 patients who had no EV at baseline and was assessed using a Cox regression model. Patients were censored at 5 years of follow-up or the day they went off the protocol. This model was adjusted for the stratification variables (Mayo risk score and histological staging I or II versus III or IV).
Sample size calculations were made assuming that UDCA would halve the risk of a primary endpoint which was based on projections from our pilot study.13 Based on our previous study, we expected 35% of patients to reach a primary endpoint in 5 years.14 With α = 0.05 and power = 80%, we estimated a need to recruit at least 149 patients.
All analyses used a 5% two-sided type I error rate. Analyses were performed with the SPSS statistical software package (SPSS, version 126.96.36.199, Windows VISTA; July 3, 2007). After a planned analysis once 75% of expected endpoints had been reached, the Data Safety and Monitoring Board reviewed the data and terminated the study due to futility.
Characteristic Data of 150 Patients with PSC.
One-hundred-fifty patients were enrolled over a 5-year period from seven sites and their baseline characteristics based on stage of liver fibrosis are shown in Table 1. The median age (IQR) of patients was 45.9 (35.8, 54.9) years with a male predominance (57.3%). Advanced liver fibrosis was present in 62 patients (41.3%) with average (median; IQR) Mayo risk score of 0.73 (0.21, 1.35). Colitis was present in 115 patients (76.7%). Forty-seven (53.4%) of the patients with mild liver fibrosis were treated with UDCA, as compared to 29 (46.8%) of the patients with advanced liver fibrosis.
|Variables Median (Interquartile range; IQR) or Number (%)||Mild Liver Fibrosis (N = 88)||Advanced Liver Fibrosis (N = 62)||P Value*|
|Age (years)||44.6 (35.4, 53.3)||48.7 (40, 58.1)||0.09|
|Sex, % male||52 (59.1)||34 (54.8)||0.60|
|Patients with history of IBD||69 (78.4)||46 (74.2)||0.55|
|Mayo risk score at baseline||−0.004 (−0.50, 0.64)||0.73 (0.21, 1.35)||<0.0001*|
|Treatment with ursodeoxycholic acid||47 (53.4)||29 (46.8)||0.42|
|Presence of varices at baseline||6 (6.8)||20 (32.3)||<0.0001*|
Patients with advanced liver fibrosis had significantly higher Mayo risk score, higher total bilirubin, higher AST level and higher AST/alanine aminotransferase (ALT) ratio at baseline, lower platelet count, lower albumin, and had varices at baseline more often than those with mild liver fibrosis. Table 2 shows the laboratory tests at baseline and at the second year of follow-up. Patients with advanced liver fibrosis had significantly higher AST, ALT, TB, AST/ALT ratio, and ALP, with a lower platelet count, hemoglobin, albumin level than those with mild liver fibrosis. In a multivariable logistic regression model, higher Mayo risk score and higher AST/ALT ratio remained significantly associated with the presence of advanced liver fibrosis (odds ratio [OR] = 2.4, P = 0.002, 95% confidence interval [CI] 1.4-4.2, and OR = 8.7, P = 0.003, 95% CI 2.1-37.1) as shown in Table 3.
|Laboratory Tests Median (IQR) or Number (%)||Mild Liver Fibrosis (N = 88)||Advanced Liver Fibrosis (N = 62)||P Value*|
|A. At baseline|
|ALT (U/L)||110 (63.5, 193)||104.5 (70.5, 147.3)||0.59|
|AST (U/L)||72 (42, 112)||87 (69, 138.8)||0.004*|
|AST/ALT ratio||0.61 (0.51, 0.83)||0.88 (0.68, 1.26)||<0.0001*|
|Albumin (g/dL)||4.1 (3.9, 4.3)||3.8 (3.5, 4.2)||<0.0001*|
|Total bilirubin (mg/dL)||0.8 (0.6, 1.2)||1.2 (0.8, 1.8)||<0.0001*|
|ALP (U/L)||433 (246, 694)||525 (340.5, 797.5)||0.08|
|Hemoglobin (g/dL)||13.8 (12.7, 15.1)||13.2 (12.2, 14.7)||0.13|
|White cell count (× 103/L)||6.4 (5.4, 8.1)||6.3 (4.5, 7.7)||0.14|
|Platelet (× 109/L)||265 (210, 332)||216 (152, 289)||0.0009*|
|B. At the Second Year of Follow-Up|
|HDL-cholesterol (mg/dL)||62.5 (49.8, 76.3)||54 (40, 74)||0.10|
|ALT (U/L)||51.5 (34.3, 83.8)||71 (39, 133.8)||0.05*|
|AST (U/L)||42 (30, 71)||71.5 (47.8, 102.3)||0.0001*|
|AST/ALT ratio||0.80 (0.65, 1.02)||1.10 (0.73, 1.31)||0.01*|
|Total bilirubin (mg/dL)||0.8 (0.6, 1.2)||1.3 (0.9, 2.7)||0.0002*|
|Albumin (g/dL)||4.2 (3.9, 4.4)||3.8 (3.5, 4.1)||<0.0001*|
|ALP (U/L)||232 (141, 342)||286 (175.5, 415.3)||0.03*|
|Hemoglobin (g/dL)||14.2 (12.9, 15.3)||13.3 (11.9, 14.5)||0.01*|
|White cell count (× 103/L)||6.4 (5.2, 7.4)||4.8 (3.5, 7.8)||0.02*|
|Platelet (× 109/L)||256 (204, 331)||194 (107, 275)||0.001*|
Predicting Varices at Baseline.
Table 4 shows that patients with varices at baseline had significantly higher Mayo risk score, higher TB, higher AST/ALT ratio at baseline, a high proportion of patients with advanced liver fibrosis at baseline, lower hemoglobin, lower white blood cell and platelet count, lower albumin, and lower triglyceride than those without varices. In a multivariable logistic regression model with removal of the presence of advanced liver fibrosis (model 2), the higher Mayo risk score and higher AST/ALT ratio at baseline were significantly associated with the presence of varices at baseline (OR = 1.9, P = 0.04, 95% CI 1.0-3.6, and OR = 3.9, P = 0.02, 95% CI 1.3-11.8) as shown in Table 5. The ROC curve for the presence of varices at baseline was derived and showed that the Mayo risk score of 0.87 was the best cutoff value based on the sensitivity (65.4%), specificity (78.2%), positive predictive value (PPV; 38.6%), and negative predictive value (NPV; 91.5%) with AUC of 0.75. The best cutoff value of AST/ALT ratio at baseline for predicting varices at baseline was 1.12 with a sensitivity of 47.8%, specificity of 87%, PPV of 42.3%, NPV of 89.2%, and AUC of 0.69.
|Clinical Features Median (IQR) or Number (%)||Patients Without Varices at Baseline (N = 124)||Patients with Varices at Baseline (N = 26)||P Value*|
|Sex, % male||72 (58.1)||14 (53.9)||0.69|
|Age (years)||45.4 (35.6, 53.9)||48.6 (42.4, 58.3)||0.26|
|Proportion of patients with advanced liver fibrosis at baseline||42 (33.9)||20 (76.9)||<0.001*|
|AST at baseline (U/L)||77 (50, 115)||95 (69.8, 142.5)||0.06|
|AST/ALT ratio at baseline||0.68 (0.54, 0.93)||0.88 (0.74, 1.47)||0.004*|
|Proportion of patients with high AST/ALT ratio (>1.12) at baseline||15 (12.1)||11 (42.3)||<0.001*|
|Albumin at baseline (g/dL)||4.1 (3.8, 4.3)||3.8 (3.5, 4.0)||<0.001*|
|Total bilirubin at baseline (mg/dL)||0.9 (0.6, 1.2)||1.3 (0.98, 2.03)||<0.001*|
|Triglyceride at baseline (mg/dL)||103 (73, 139)||77.5 (60.8, 112.5)||0.01*|
|Hemoglobin at baseline (g/dL)||13.8 (12.7, 14.9)||12.9 (12.2, 14.3)||0.16|
|White cell counts at baseline (× 103/L)||6.4 (5.4, 8.1)||5.3 (4.2, 6.8)||0.03*|
|Platelet at baseline (× 109/L)||253.5 (203.3, 322)||170 (111.8, 267.8)||0.001*|
|Mayo risk score at baseline||0.15 (−0.38, 0.77)||0.92 (0.35, 1.43)||<0.001*|
|Multivariate Analysis||B||SE||P Value||OR||95% CI (OR)|
|Presence of advance liver fibrosis||1.58||0.57||0.005*||4.9||1.6–14.9|
|High AST/ALT ratio (>1.12) at baseline||1.41||0.55||0.01*||4.1||1.4–11.9|
|High AST/ALT ratio (>1.12) at baseline||1.36||0.57||0.02*||3.9||1.3–11.8|
|Mayo risk score at baseline||0.65||0.32||0.04*||1.9||1.0–3.6|
Predicting New Varices.
From 124 patients with PSC who had no varices at initial endoscopy, 25 patients had new varices (20.2%) by the end of the study. The size of new EV were graded as small in 20 patients (80%), moderate in three patients (12%), and large in two patients (8%). Portal hypertensive gastropathy was present in 21 of 124 patients (16.9%) with the fundus or body the predominant area. Other endoscopic findings were esophageal ulcer or erosion (n = 10, 8.1%), gastric ulcer or erosion (n = 9, 7.3%), and duodenal ulcer or erosion (n = 4, 3.2%). Six patients (4.8%) died during the follow-up period. The causes of deaths were liver-related (three patients), unknown cause (two patients), and coronary heart disease (one patient).
Table 6 shows the univariate analysis of predictors for developing new varices in 124 patients with PSC who had no varices at initial endoscopy which found that patients with new varices had significantly more frequent treatment with UDCA, higher AST/ALT ratio, lower albumin, and lower hemoglobin and platelet count at baseline than those without varices. At the second year of follow-up, patients with new varices had significantly lower albumin, lower hemoglobin, white blood cell, and platelet count with higher AST/ALT ratio, higher TB, and higher % rate change of TB and platelet counts per year than those without varices.
|Clinical Features Median (IQR) or Number (%)||Patients Without Varices (N = 99)||Patients with Varices (N = 25)||P Value*|
|Treatment with Ursodeoxycholic acid||45 (45.5)||18 (72.0)||0.02*|
|Proportion of patients with advanced liver fibrosis at baseline||30 (30.3)||12 (48.0)||0.09|
|ALT at baseline (U/L)||110 (73, 214)||80 (55, 174)||0.13|
|AST/ALT ratio at baseline||0.6 (0.5, 0.9)||0.9 (0.6, 1.2)||0.01*|
|ALP (U/L)||431 (259, 710)||576 (383, 774)||0.16|
|Total bilirubin (mg/dL)||0.8 (0.6, 1.2)||1.1 (0.7, 1.6)||0.08|
|Albumin at baseline (g/dL)||4.1 (3.9, 4.3)||3.9 (3.6, 4.2)||0.05*|
|Total protein at baseline (g/dL)||9.9 (9.2, 12.4)||11.4 (9.5, 12.7)||0.15|
|Triglyceride at baseline (mg/dL)||108 (76, 144.8)||83 (70, 121)||0.14|
|HDL-cholesterol at baseline (mg/dL)||62.5 (48.3, 75)||70 (59, 77)||0.08|
|Hemoglobin at baseline (g/dL)||14.0 (12.8, 14.9)||13.2 (11.5, 14.3)||0.05*|
|Platelet at baseline (× 109/L)||263 (211, 327)||225 (155, 283.5)||0.02*|
|Mayo risk score at baseline||0.13 (−0.43, 0.75)||0.53 (−0.21, 1.29)||0.10|
|Albumin at the second year (g/dL)||4.2 (3.9, 4.4)||3.8 (3.5, 4.1)||0.0003*|
|Total bilirubin at the second year (mg/dL)||0.9 (0.6, 1.3)||1.8 (1.0, 3.3)||0.0003*|
|AST/ALT ratio at the second year||0.8 (0.6, 1.0)||1.2 (0.8, 1.4)||0.001*|
|AST at the second year (U/L)||47.5 (31, 84.3)||63 (42.5, 102)||0.06|
|ALP at the second year (U/L)||252 (141, 377)||274 (180, 574)||0.16|
|Triglyceride at the second year (mg/dL)||102 (68.3, 134)||82.5 (51.5, 105.5)||0.13|
|Hemoglobin at the second year (g/dL)||14.0 (13.1, 15.3)||13.2 (11.5, 14.4)||0.01*|
|White cell count at the second year||6.5 (5.3, 8.4)||4.8 (3.5, 6.9)||0.003*|
|Platelet at the second year (× 109/L)||264 (212, 331)||177 (98.5, 264)||0.0003*|
|Rate of total bilirubin change per year (%)||3.6 (−9.3, 25.0)||16.7 (3.6, 70.0)||0.003*|
|Rate of platelet count change per year (%)||−0.9 (−5.3, 6.6)||−5.6 (−16.9, −2.2)||0.0003*|
|Duration from randomization to the first presence of varices (years)||3.9 (3.0, 4.9)||2.0 (1.9, 3.5)||0.0004*|
In a Cox regression model, after adjusting for all significant variables from the univariate analysis (model 1), only treatment with UDCA, lower platelet count and higher TB at 2 years were significantly associated with the presence of new varices (Table 7). After removal of treatment with UDCA in model 2, the lower platelet count and higher TB at 2 years remained significantly associated with the presence of new varices. The median (IQR) platelet count and TB at the second year of 25 patients with new varices were 177 (× 109/L) (98.5-264) and 1.8 mg/dL (1.0-3.3), respectively. Using the ROC curves for the detection of new varices, we found that platelet count at the second year of follow-up of 205 (× 109/L) was the best cutoff value based on a sensitivity of 62.5%, specificity of 80.5%, PPV of 50%, and NPV of 87.3% with AUC of 0.75. The best cutoff value of TB level at the second year of follow-up for the detection of new varices was 1.7 mg/dL with a sensitivity of 56%, specificity of 87.7%, PPV of 58.3%, NPV of 86.6%, and AUC of 0.74.
|Multivariate Analysis||B||SE||P Value||OR||95% CI (OR)|
|Total bilirubin at the second year (mg/dL)||0.45||0.12||<0.001*||1.6||1.2–2.0|
|Platelet at the second year (× 109/L)||−0.01||0.003||0.001*||0.989||0.983–0.995|
|Treatment with UDCA||1.26||0.58||0.029*||3.5||1.1–10.9|
|Total bilirubin at the second year (mg/dL)||0.43||0.13||0.001*||1.5||1.2–2.0|
|Platelet at the second year (× 109/L)||−0.01||0.003||0.004*||0.992||0.986–0.997|
A cumulative hazard curve of developing new varices in 124 patients at 2 years of follow-up showed that the cumulative hazard of developing new varices was 5.9%. (A supporting figure 1).
We demonstrate that a higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of advanced liver fibrosis. Recently, the European Association for the Study of the Liver clinical practice guidelines suggested that liver biopsy is not essential for the diagnosis of PSC.15 Thus, without the variables of the presence of liver fibrosis, the higher Mayo risk score and higher AST/ALT ratio at baseline were significantly associated with the presence of varices at initial endoscopy. We also found that treatment with UDCA, presence of lower platelet count, and higher TB at the second year of follow-up were significantly associated with an increased risk of new varices in patients with PSC who had no varices at initial endoscopy. Our study also demonstrated that treatment with high dose UDCA was the strongest predictor for the presence of new varices and should not be used in the future in these patients. The paradoxical effect of high dose UDCA in our study on increasing risk of varices was unexpected.
Currently, there are no studies to determine the prognostic predictors for new varices in patients with PSC who have mild degrees of liver injury. Two-thirds of our patients had histologic stage 1-2 with an average (median; IQR) Mayo risk score of 0.296 (−0.273 to 0.931). We used a standard protocol to follow patients every 3 months with blood tests in our randomized control trial and found that TB and platelet count at the second year of follow-up were useful predictors for an increased risk of new varices, regardless of treatment with UDCA.
From the report of the Baveno IV consensus, the hepatic vein pressure gradient is the most reliable predictor to detect varices16; however, this method of hemodynamic monitoring is not available in many centers especially in developing countries. Screening all patients with cirrhosis with endoscopy to detect the presence of varices may also result in a large number of unnecessary procedures and high costs.17 Noninvasive predictors of EV including Mayo risk score with value of at least 0.87 or a higher AST/ALT ratio of at least 1.12 may be used to select patients with PSC for screening of varices (A supporting Table 1). With clinical evaluation and blood tests during follow-up, the platelet count (<205,000/mm3) and TB level (>1.7 mg/dL) at the second year of follow-up may be used as alternative markers for patient selection to undergo endoscopy. Bressler et al.18 showed similar risk factors for EV at initial evaluation and suggested that patients with primary biliary cirrhosis or PSC with a platelet count <200,000/mm3, albumin level <40 g/L, and TB level higher than 20 μmol/L (or 1.17 mg/dL) should be screened for EV. However, the limitation of this study is the small number of patients with PSC (n = 9). A recent multicenter longitudinal study investigated the relationship between varices and platelet count at the time of endoscopy.19 They found that the platelet count was not a good prognostic marker for gastroesophageal varices; however, hepatic vein pressure gradient was significantly correlated with platelet count at baseline, year 1, and year 5.19 This study was limited by the exclusion of patients with PSC and/or primary biliary cirrhosis.
Our results showed that 6% of patients with PSC develop new varices at 2 years of follow-up, which was different from the result of a previous study performed by Merli et al. showing that the incidence of EV was 5% at 1 year and 28% at 3 years.20 The different rate of new varices detection may be explained by the different study patient populations. Merli et al. included patients with cirrhosis caused by viral hepatitis B, viral hepatitis C, and/or alcohol.20 Our current results also support the American Association for the Study of Liver Diseases guideline of endoscopic surveillance in patients with cirrhosis who had no varices at initial endoscopy with upper endoscopy performed every 2-3 years.21
Our study is the first prospective study to report that a higher Mayo risk score and higher AST/ALT ratio at baseline are good predictors of varices at initial endoscopy with OR of 1.9 and 3.9, respectively, but not as good a predictor of developing new varices in patients with PSC who had no varices at initial endoscopy. Thus, Mayo risk score and AST/ALT ratio at baseline seem to be more useful than liver biopsy for initial evaluation of varices in patients with PSC. A Mayo risk score without the need for a liver biopsy is a simple and noninvasive tool, and it should be calculated for all patients with PSC at initial consultation to obtain 4-year survival estimates.10
Twenty percent of our patients with new varices had either moderate or large varices on endoscopy. These patients should be considered for prophylactic medical or endoscopic band ligation therapy according to current guidelines.16, 21 Eighty percent of our patients with new varices had small varices on endoscopy. Currently, there is limited information to support the prophylactic treatment of patients with new small varices.22 There are no studies to date that have evaluated the progression of small varices in patients with PSC. A previous study from Italy which enrolled patients with cirrhosis caused by alcohol or viral hepatitis showed that the rate of progression from small varices to larger varices was 12% at the first year and 25% at the second year.20 To summarize our results, we propose an algorithm for screening and surveillance of varices in patients with PSC (Fig. 1). Further study to identify the significant predictors of enlarged varices or the risk factors for bleeding from varices in patients with PSC should be performed.
Our study has some limitations. First, our study did not have complete follow-up at 5 years, because 75% of the expected endpoints had been reached when the Data Safety and Monitoring Board reviewed the data and terminated the study due to futility. Second, only 33% of our assessed patients were enrolled due to several exclusion criteria. In this regard, the extrapolation to general patients with PSC has to be done with caution. Lastly, we did not measure the maximum spleen bipolar diameter, and thus we cannot calculate the platelet count/spleen diameter ratio, which is another noninvasive diagnostic tool for EV.23, 24
In conclusion, a higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of advanced liver fibrosis. The higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of varices at initial endoscopy. The presence of higher TB level at the second year and lower platelet count at the second year of follow-up were good predictors of the presence of new varices in patients with PSC who had no varices at initial endoscopy.
- 4Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol 1999; 94: 3285–3291., , , , , , et al.Direct Link:
- 7Is there a role for liver biopsy in primary sclerosing cholangitis? Am J Gastroenterol 2003; 98: 1155–1158., , .Direct Link:
- 13High-dose ursodeoxycholic acid as a therapy for patients with primary sclerosing cholangitis. Am J Gastroenterol 2001; 96: 1558–1562., , , , .Direct Link:
- 23Platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study. Am J Gastroenterol 2006; 101: 2511–2519., , , , , , et al.Direct Link:
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