Autoimmune, Cholestatic and Biliary Disease

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Early predictors of corticosteroid treatment failure in icteric presentations of autoimmune hepatitis †

  1. Andrew D. Yeoman,
  2. Rachel H. Westbrook,
  3. Yoh Zen,
  4. Paola Maninchedda,
  5. Bernard C. Portmann,
  6. John Devlin,
  7. John G. O'Grady,
  8. Phillip M. Harrison,
  9. Michael A. Heneghan*

Article first published online: 2 MAR 2011

DOI: 10.1002/hep.24141

Issue

Hepatology

Hepatology

Volume 53, Issue 3, pages 926–934, March 2011

Additional Information

How to Cite

Yeoman, A. D., Westbrook, R. H., Zen, Y., Maninchedda, P., Portmann, B. C., Devlin, J., O'Grady, J. G., Harrison, P. M. and Heneghan, M. A. (2011), Early predictors of corticosteroid treatment failure in icteric presentations of autoimmune hepatitis . Hepatology, 53: 926–934. doi: 10.1002/hep.24141

Author Information

  1. From the Institute of Liver Studies, Kings College Hospital NHS Trust Foundation Trust, Denmark Hill, London, UK

*Consultant Hepatologist, Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom, SE5 9RS

  1. †

    Potential conflict of interest: Nothing to report.

Publication History

  1. Issue published online: 2 MAR 2011
  2. Article first published online: 2 MAR 2011
  3. Accepted manuscript online: 22 DEC 2010 03:58PM EST
  4. Manuscript Accepted: 12 DEC 2010
  5. Manuscript Received: 15 SEP 2010

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Abstract

Autoimmune hepatitis (AIH) typically responds to treatment in 90% of patients. Early prediction of treatment outcome would be advantageous in clinical practice. We evaluated whether parameters at initiation of therapy or changes in these parameters at day 3 and day 7 following corticosteroid initiation predicted treatment failure. Treatment-naive, jaundiced patients presenting to our tertiary unit between 1999-2009 were identified and mathematical models of prognosis in liver disease scores calculated at day 0, day 3, and day 7. Overall, 72 patients were identified (48 women, 24 men). Treatment failure occurred in 18% (13/72) of patients. At diagnosis, higher median bilirubin (451 μmol/L versus 262 μmol/L, P = 0.02), INR (1.62 versus 1.33, P = 0.005), model for endstage liver (MELD) score (26 versus 20, P = 0.02), MELD-sodium (Na) score (27 versus 22, P = 0.03) and United Kingdom endstage liver disease score (UKELD) score (59 versus 57, P = 0.01) significantly correlated with treatment failure. Analysis of area under the receiver operator characteristic curve (AUROC) values at day 7 identified change (Δ) bilirubin (AUROC 0.68), Δ creatinine (0.69), Δ MELD (0.79), Δ MELD-Na (0.83) and Δ UKELD (0.83) best predicted treatment failure. Specifically, a fall in UKELD of less than 2 points predicted treatment failure with a sensitivity of 85% and specificity of 68%. Of 13 treatment failures, nine required second-line immunosuppression, three required emergency transplant, and one died of sepsis. In total, four patients died in the treatment failure group compared with one in the responder group (4/13 = 31% versus 1/59 = 1.7%, P = 0.003). Conclusion: Approximately 20% of icteric AIH presentations fail corticosteroid therapy. This is associated with significant mortality and the need for emergency transplantation. Treatment failure is best predicted by change in MELD-Na and UKELD at day 7. Early identification of nonresponders may allow timely escalation of immunosuppression to prevent clinical deterioration. (HEPATOLOGY 2011;)

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