Alcohol-related liver disease phenotype impacts survival after an acute variceal bleeding episode.

Abstract:

BACKGROUND & AIMS

Alcohol-related hepatitis (AH) encompasses a high mortality. AH might be a concomitant event in patients with acute variceal bleeding (AVB). The current study aimed to assess the prevalence of AH in patients with AVB and to compare the clinical outcomes of AH patients to other alcohol-related liver disease (ALD) phenotypes and viral cirrhosis.

METHODS

Multicentre, observational study including 916 patients with AVB falling under the next categories: AH (n = 99), ALD cirrhosis actively drinking (d-ALD) (n = 285), ALD cirrhosis abstinent from alcohol (a-ALD) (n = 227) and viral cirrhosis (n = 305). We used a Cox proportional hazards model to calculate adjusted hazard ratio (HR) of death adjusted by MELD.

RESULTS

The prevalence of AH was 16% considering only ALD patients. AH patients exhibited more complications. Forty-two days transplant-free survival was worse among AH, but statistical differences were only observed between AH and d-ALD groups (84 vs. 93%; p = 0.005), when adjusted by MELD no differences were observed between AH and the other groups. At one-year, survival of AH patients (72.7%) was similar to the other groups; when adjusted by MELD mortality HR was better in AH compared to a-ALD (0.48; 0.29-0.8, p = 0.004). Finally, active drinkers who remained abstinent presented better survival, independently of having AH.

CONCLUSIONS

Contrary to expected, AH patients with AVB present no worse one-year survival than other patients with different alcohol-related phenotypes or viral cirrhosis. Abstinence influences long-term survival and could explain these counterintuitive results.

© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Keywords: abstinence, alcohol, alcohol-related hepatitis, cirrhosis, upper gastrointestinal bleeding

References: WHO. World Health Organization. Global Status Report on Alcohol and Health. 2018. Accessed 2018. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/
Julien J, Ayer T, Bethea ED, Tapper EB, Chhatwal J. Projected prevalence and mortality associated with alcohol-related liver disease in the USA, 2019-40: a modelling study. Lancet Public Health. 2020;5(6):e316-e323.
Crabb DW, Bataller R, Chalasani NP, et al. Standard definitions and common data elements for clinical trials in patients with alcoholic hepatitis: recommendation from the NIAAA alcoholic hepatitis consortia. Gastroenterology. 2016;150(4):785-790.
EASL Clinical Practice Guidelines. Management of alcohol-related liver disease. J Hepatol. 2018;69(1):154-181.
Rudler M, Mouri S, Charlotte F, et al. Prognosis of treated severe alcoholic hepatitis in patients with gastrointestinal bleeding. J Hepatol. 2015;62(4):816-821.
Thabut D, Pauwels A, Carbonell N, et al. Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: a large multicentre audit with real-life results. J Hepatol. 2017;68(1):73-81.
Conejo I, Augustin S, Pons M, et al. Alcohol consumption and risk of infection after a variceal bleeding in low-risk patients. Liver Int. 2016;36(7):994-1001.
Hernández-Gea V, Procopet B, Giráldez Á, et al. Preemptive-TIPS improves outcome in high-risk variceal bleeding: an observational study. Hepatology (Baltimore, MD). 2019;69(1):282-293.
Trebicka J, Gu W, Ibáñez-Samaniego L, et al. Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS. J Hepatol. 2020;73(5):1082-1091.
Martínez J, Hernández-Gea V, Rodríguez-de-Santiago E, et al. Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis. J Hepatol. 2021;75(2):342-350.
Abraldes JG, Villanueva C, Bañares R, et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol. 2008;48(2):229-236.
Altamirano J, Lopez-Pelayo H, Michelena J, et al. Alcohol abstinence in patients surviving an episode of alcoholic hepatitis: Prediction and impact on long-term survival. Hepatology (Baltimore, MD). 2017;66(6):1842-1853.
Muntaner L, Altamirano JT, Augustin S, et al. High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding. Liver Int. 2010;30(8):1123-1130.
Morales-Arráez D, Ventura-Cots M, Altamirano J, et al. The MELD score is superior to the Maddrey discriminant function score to Predict short-term mortality in alcohol-associated hepatitis: A global study. Am J Gastroenterol. 2022;117(2):301-310.
Shah ND, Ventura-Cots M, Abraldes JG, et al. Alcohol-related liver disease is rarely detected at early stages compared with liver diseases of other etiologies worldwide. Clin Gastroenterol Hepatol. 2019;17:2320-2329.e12.

Authors

• Juan G Abraldes |
• Agustín Albillos |
• Edilmar Alvarado |
• Lucio Amitrano |
• Rafael Bañares |
• Ramon Bataller |
• Jaime Bosch |
• Christophe Bureau |
• Jose L Calleja |
• Nuria Cañete |
• Meritxell Casas |
• Jose Castellote |
• Alessandra Dell'Era |
• Arnulf Ferlitsch |
• Carlos N Ferreira |
• Juan C García-Pagán |
• Joan Genescà |
• Álvaro Giráldez |
• Lise L Gluud |
• Henning Gronbaek |
• Maria A Guardascione |
• Virginia Hernández-Gea |
• Manuel Hernández-Guerra |
• Luis Ibañez-Samaniego |
• Christian Jansen |
• Aleksander Krag |
• Wim Laleman |
• Elba Llop |
• Javier Martínez |
• Helena Masnou |
• Jose L Mundi |
• Frederik Nevens |
• J M Palazon |
• Massimo Primignani |
• Bogdan Procopet |
• Marie A Robic |
• Susana Rodrigues |
• Manuel Rodríguez |
• Manuel Romero-Gómez |
• Marika Rudler |
• Romano Sassatelli |
• Marco Senzolo |
• Gilberto Silva-Junior |
• Marcel Tantau |
• Dominique Thabut |
• Jonel Trebicka |
• Meritxell Ventura-Cots |
• Ares Villagrasa |
• Càndid Villanueva |
• Alexander Zipprich |