Mesh : Humans End Stage Liver Disease Severity of Illness Index Hepatitis, Alcoholic / diagnosis Aspartate Aminotransferases Bilirubin

来  源:   DOI:10.1097/HC9.0000000000000404   PDF(Pubmed)

Abstract:
BACKGROUND: The precision of clinical criteria and the utility of liver biopsy for diagnosis or prognosis remain unclear in patients with alcohol-associated hepatitis (AH). We systematically reviewed the literature to answer these questions.
METHODS: Four databases were searched for studies describing the precision of clinical criteria (National Institute on Alcohol Abuse and Alcoholism, European Association for Study of Liver, or classical) and the role of histology in AH. The precision(positive predictive value) of criteria was pooled through random-effects meta-analysis, and its variation was investigated through subgroups and meta-regression of study-level factors with their percent contribution to variation (R2). The risk of bias among studies was evaluated through the QUADAS2 tool (PROSPERO-ID-CRD4203457250).
RESULTS: Of 4320 studies, 18 in the systematic review and 15 (10/5: low/high risk of bias, N=1639) were included in the meta-analysis. The pooled precision of clinical criteria was 80.2% (95% CI: 69.7-89.7, I2:93%, p < 0.01), higher in studies with severe AH (mean-Model for End-Stage Liver Disease > 20) versus moderate AH (mean-Model for End-Stage Liver Disease < 20): 92% versus 67.1%, p < 0.01, and in studies with serum bilirubin cutoff 5 versus 3 mg/dL (88.5% vs.78.8%, p = 0.01). The factors contributing to variation in precision were Model for End-Stage Liver Disease (R2:72.7%), upper gastrointestinal bleed (R2:56.3%), aspartate aminotransferase:aspartate aminotransferase ratio (R2:100%), clinical criteria (R2:40.9%), bilirubin (R2:22.5%), and Mallory body on histology (R2:19.1%).The net inter-pathologist agreement for histologic findings of AH was variable (0.33-0.97), best among 2 studies describing AH through simple and uniform criteria, including steatosis, ballooning, and neutrophilic inflammation. Few studies reported the utility of histology in estimating steroid responsiveness (N = 1) and patient prognosis (N = 4); however, very broad septa, pericellular fibrosis, and cholestasis were associated with mortality. Bilirubinostasis was associated with infection in 1 study.
CONCLUSIONS: Clinical criteria are reasonably precise for diagnosing severe AH, while there is an unmet need for better criteria for diagnosing moderate AH. Histologic diagnosis of AH should be simple and uniform.
摘要:
背景:酒精相关肝炎(AH)患者的临床标准的准确性和肝活检诊断或预后的实用性尚不清楚。我们系统地回顾了文献来回答这些问题。
方法:在四个数据库中搜索描述临床标准精确度的研究(美国国家酒精滥用和酒精中毒研究所,欧洲肝脏研究协会,或经典)以及组织学在AH中的作用。标准的精确度(阳性预测值)通过随机效应荟萃分析进行汇总,通过亚组和研究水平因子的元回归及其对变异的贡献百分比(R2)来调查其变异。通过QUADAS2工具(PROSPERO-ID-CRD4203457250)评估研究中的偏倚风险。
结果:在4320项研究中,系统评价中18人,15人(10/5:低/高风险偏差,N=1639)被纳入荟萃分析。临床标准的合并精度为80.2%(95%CI:69.7-89.7,I2:93%,p<0.01),在重度AH(终末期肝病的平均模型>20)与中度AH(终末期肝病的平均模型<20)的研究中更高:92%对67.1%,p<0.01,并且在血清胆红素截止值5与3mg/dL的研究中(88.5%vs.78.8%,p=0.01)。导致精度变化的因素是终末期肝病模型(R2:72.7%),上消化道出血(R2:56.3%),天冬氨酸氨基转移酶:天冬氨酸氨基转移酶比例(R2:100%),临床标准(R2:40.9%),胆红素(R2:22.5%),和Mallory身体组织学(R2:19.1%)。病理学家之间对AH组织学发现的净一致是可变的(0.33-0.97),在通过简单和统一的标准描述AH的两项研究中,最好的是,包括脂肪变性,气球,和嗜中性粒细胞炎症。很少有研究报道组织学在评估类固醇反应性(N=1)和患者预后(N=4)中的效用;然而,非常宽的隔垫,细胞周纤维化,胆汁淤积与死亡率相关.在1项研究中,胆红素抑制与感染有关。
结论:临床标准对于诊断重度AH是相当精确的,虽然对诊断中度AH的更好标准的需求尚未满足。AH的组织学诊断应该是简单和统一的。
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