Moderate Alcoholic Hepatitis

Clemente‐Sánchez, Ana; Oliveira-Mello, Aline; Bataller, R.

doi:10.1016/j.cld.2021.03.001

Cited by 11 publications

(11 citation statements)

References 60 publications

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“…For patients with moderate AH, less is known about the natural history; however, the 1-year mortality ranges from 10% to 20% (162)(163)(164). In a study of all patients with AH, survival at 12 months among patients with moderate AH was 3-fold higher compared with those with severe AH (163).…”

Section: Ahmentioning

confidence: 99%

ACG Clinical Guideline: Alcohol-Associated Liver Disease

Jophlin,

Singal,

Bataller

et al. 2023

Am J Gastroenterol

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Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%–50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%–60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.

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Section: Ahmentioning

confidence: 99%

ACG Clinical Guideline: Alcohol-Associated Liver Disease

Jophlin,

Singal,

Bataller

et al. 2023

Am J Gastroenterol

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“…ischaemic hepatitis, drug-induced liver injury). MAH and sAH were stratified by admission MELD score ≤ or > 20 3,11,14 respectively. Information on alcohol intake was obtained from chart review (i.e.…”

Section: Study Populationmentioning

confidence: 99%

“…[7][8][9][10] However, there are few data describing outcomes of hospitalized patients with moderate AH (mAH, MELD ≤20). 11 Thus far, studies evaluating hospitalized mAH have been limited by sample size, heterogenous definitions for AH severity and incomplete patient demographic and clinical course characteristics. 12,13 Better characterization of hospitalized patients with mAH and their outcomes are critical to improving prognostication and to targeting personalized care during and after hospital discharge.…”

Section: Introductionmentioning

confidence: 99%

“…Hospitalized patients with sAH have well‐described clinical courses and outcomes 7–10 . However, there are few data describing outcomes of hospitalized patients with moderate AH (mAH, MELD ≤20) 11 . Thus far, studies evaluating hospitalized mAH have been limited by sample size, heterogenous definitions for AH severity and incomplete patient demographic and clinical course characteristics 12,13 .…”

Section: Introductionmentioning

confidence: 99%

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Clinical characteristics and prognosis of hospitalized patients with moderate alcohol‐associated hepatitis

Gaurnizo‐Ortiz,

Nephew,

Vilar‐Gomez

et al. 2023

Liver International

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Background and AimsLittle is known about the clinical characteristics and prognosis of hospitalized patients with moderate alcohol‐associated hepatitis (mAH) as compared to severe alcohol‐associated hepatitis (sAH). Therefore, we aimed to describe the clinical characteristics and risk factors associated with mortality in hospitalized mAH patients.MethodsPatients hospitalized with alcohol‐associated hepatitis (AH) from 1 January 2010 to 31 December 2020 at a large US healthcare system [11 hospitals, one liver transplant centre] were retrospectively analysed for outcomes. Primary outcome was 90‐day mortality. AH and mAH were defined according to NIAAA Alcoholic Hepatitis Consortia and Model for End‐stage Liver Disease Score ≤ 20 respectively. Multivariable Cox regression analysis was performed to identify independent risk factors associated with 90‐day mortality.Results1504 AH patients were hospitalized during the study period, of whom 39% (n = 590) had mAH. Compared to sAH patients, mAH patients were older (50 vs. 48 years, p < 0.001) and less likely to have underlying cirrhosis (74% vs. 83%, p < 0.001). There were no differences between the two groups for median alcohol intake g/day (mAH 140.0 vs. sAH 112.0, p = 0.071). The cumulative proportion surviving at 90 days was 88% in mAH versus 62% in sAH (p < 0.001). On multivariable analysis, older age [HR 1.03 (95% CI 1.00–1.06), p = 0.020], corticosteroid use [HR 1.80 (95% CI 1.06–3.06), p = 0.030] and acute kidney injury (AKI) [HR 2.43 (95% CI 1.33–4.47), p = 0.004] were independently associated with 90‐day mortality.ConclusionsmAH carries a 12% mortality rate at 90 days. Age, AKI and corticosteroid use were associated with an increased risk for 90‐day mortality. Avoidance of corticosteroids and strategies to reduce the risk of AKI could improve outcomes in mAH patients.

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“…Alcohol-associated hepatitis (AH) is the most severe form of alcohol-associated liver disease, which is associated with high short-term mortality. 1 2 Until few years ago, the criteria for the clinical diagnosis of AH were variable. Often, it was defined as a recent onset of jaundice with/without other features of decompensation in a patient with ongoing alcohol abuse and/or features of steatohepatitis on liver biopsy.…”

Section: Introductionmentioning

confidence: 99%

Clinical criteria accurately diagnose severe but not moderate alcohol-associated hepatitis: A systematic review and meta-analysis

Verma,

Mehtani,

Haiar

et al. 2024

Hepatology Communications

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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 (R 2). 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, I 2:93%, 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 (R 2:72.7%), upper gastrointestinal bleed (R 2:56.3%), aspartate aminotransferase:aspartate aminotransferase ratio (R 2:100%), clinical criteria (R 2:40.9%), bilirubin (R 2:22.5%), and Mallory body on histology (R 2:19.1%). 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.

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Moderate Alcoholic Hepatitis

Cited by 11 publications

References 60 publications

ACG Clinical Guideline: Alcohol-Associated Liver Disease

ACG Clinical Guideline: Alcohol-Associated Liver Disease

Clinical characteristics and prognosis of hospitalized patients with moderate alcohol‐associated hepatitis

Clinical criteria accurately diagnose severe but not moderate alcohol-associated hepatitis: A systematic review and meta-analysis

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