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COHORTE DE PACIENTES CON CIRROSIS HEPÁTICA

COHORTE DE PACIENTES CON CIRROSIS HEPÁTICA . Dr. José R Arribas Unidad VIH Servicio de Medicina Interna. Morbidity and mortality in HIV infected patients with compensated and decompensated cirrhosis: prospective cohort of 373 patients.

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COHORTE DE PACIENTES CON CIRROSIS HEPÁTICA

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  1. COHORTE DE PACIENTES CON CIRROSIS HEPÁTICA Dr. José R Arribas Unidad VIH Servicio de Medicina Interna

  2. Morbidity and mortality in HIV infected patients with compensated and decompensated cirrhosis: prospective cohort of 373 patients M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, JR Arribas and the GESIDA 37/03-FIPSE 364665/03 Study Group. Oral Presentation at EACS2007 PS8/4

  3. OBJECTIVE To evaluate morbidity/mortality in HIV-infected patients with compensated vs decompensated liver cirrhosis.

  4. STUDY DESIGN (1) • Multicenter national prospective cohort. • País Vasco • H. Virgen de Aranzazu. • Valencia • H. General Universitario Valencia. • Barcelona • H. Clinic y Provincial. • H. Germans Trias i Pujol. • Madrid • H. Príncipe de Asturias. • H. Gregorio Marañón. • H. Ramón y Cajal. • H. Doce de Octubre. • H. La Paz.

  5. STUDY DESIGN (2) Cirrhosis Diagnosis Biopsy: (Cirrhosis or advanced bridging fibrosis). Decompensation Gastrointestinal bleeding, ascites, hepatic encephalopathy. Bonacini Score > 8 (Am J Gastroenterol 1997;92:1302).

  6. BONACINI SCORE FOR CIRRHOSIS DIAGNOSIS Three-parameter cirrhosis discriminant score: Platelets – ALT/AST ratio – PT Cutoff for cirrhosis diagnosis = 8 Sensibility 46% Specifycity 98% Bonacini M, et al. Am J Gastroenterol 1997;92:1302.

  7. STUDY DESIGN (3) Total planned follow-up 48 months. Visits: baseline and then every 6 months. Each visit: Personal interview. Hematology, Biochemistry, Inmmunology, Virology, alfa-fetoprotein. Abdominal US. Each year: Endoscopy to detect esophageal varices (according to Schepis criteria*). Schepis et al. Hepatology 2001; 33:471-2.

  8. STUDY DESIGN (4) SURVIVAL: time from the date of entry until the first endpoint occurred. ENDPOINT: death, hepatocarcinoma or liver transplant. STATISTICAL ANALISYS: Kaplan-Meyer analysis, log rank test (comparison of survival between different groups).

  9. BASELINE CHARACTERISITICS (1)

  10. BASELINE CHARACTERISITICS (2) *Below limit of quantification (50-200) c/ml.

  11. RESULTS

  12. RESULTS

  13. SURVIVAL 0.82 Cumulative probability of survival Months N 332 302 264 169

  14. SURVIVALCompensated vs Decompensated 0.92 Cumulative probability of survival 0.53 p<0,0001 (log-rank) Months Compensated 253 241 218 141 Decompensated 78 60 45 27

  15. SURVIVAL (months)

  16. SURVIVAL Child Pugh Score A 0.96 B 0.53 Cumulative probability of survival C 0.27 p<0,0001 (log-rank) Months CP-A 219 213 196 128 CP-B 57 46 34 17 CP-C 21 12 7 5

  17. SURVIVAL (months)

  18. PROBABILITY OF FIRST DECOMPENSATION Percent wiithout decompensation Months N 253 237 210 147

  19. CONCLUSIONS HIV-infected patients with compensated liver cirrhosis had a relatively high survival with a low per year probability of first decompensation. HIV-infected patients with decompensated cirrhosis have a very poor prognosis. One third of our patients with decompensated liver cirrhosis died during the first year of follow-up. Child Pugh score apears as a good prognostic score for HIV-infected patients with liver cirrhosis. These results emphasize the critical importance of avoiding the development of end-stage liver disease in HIV-infected patients. Analysis of factors associated to survival will be available soon

  20. FACTORS ASSOCIATED WITH SURVIVAL AND FIRST HEPATIC DECOMPENSATION IN A LARGE PROSPECTIVE COHORT OF HIV-HCV CO-INFECTED PATIENTS WITH LIVER CIRRHOSIS. M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, JR Arribas and the GESIDA 37/03-FIPSE 364665/03 Study Group. Poster Presentation at CROI2008 [1057]

  21. METHODS • Prospective multicenter cohort of 331 HIV-HCV coinfected patients with cirrhosis. Median follow-up time: 18 months. • Cirrhosis diagnosis (n,%): biopsy (209, 63%), prior decompensation (86, 26%), Bonacini Score ≥ 8 (36, 11%). • Endpoints: death, hepatocarcinoma or liver transplant. • Survival defined as the time from entering in the cohort until first endpoint occurred. • The association of survival with different factors was explored in univariate and multivariate Cox proportional hazard models. Variables included: age, sex, time since cirrhosis/HIV diagnosis, alcohol intake, CD4 count (nadir, baseline and <100 at baseline), HIV viremia, suppressed HIV replication, history of anti-HCV therapy, HCV genotype, sustained viral response to anti-HCV therapy, concomitant chronic HBV, history of cirrhosis decompensation, Child Pugh score and HAART (at baseline, continuous/interrupted during follow-up). • For patients with no history of prior liver decompensation at baseline we explored variables associated with the development of first decompensation.

  22. BASELINE CHARACTERISTICS

  23. BASELINE CHARACTERISTICS

  24. ENDPOINTS • Endpoints: 62 (54 deaths, 9 hepatocarcinomas, and 1 liver transplant). • Compensated cirrhosis at baseline: 19 (16 deaths, 3 Hepatocarcinomas) • Decompensated cirrhosis at baseline: 43 (38 deaths, 6 Hepatocarcinomas, 1 Liver Transplant)

  25. Variables associated to survival. Univariate analysis

  26. Multivariate analysis: Hazard ratio of factors associated with decreased survival [HR, (CI), p]

  27. Survival according to Child Pugh Score Child Pugh A Child Pugh B Child Pugh C (N) CP-A 220 213 205 184 74 CP-B 58 48 38 30 7 CP-C 22 14 8 6 1

  28. Probability of first decompensation according to Child Pugh Score Child Pugh A Child Pugh B (N) CP-A 206 198 187 167 65 CP-B 25 19 11 8 3

  29. CONCLUSIONS • Child-Pugh scores B and C are significantly associated with decreased survival in HIV-HCV coinfected patients with cirrhosis. • Maintaining HIV viral suppression and receiving continuous HAART are associated with prolonged survival. Our study supports the continuous use of HAART in this population. • Child-Pugh B is significantly associated with the short-term risk of first hepatic decompensation. HIV-HCV coinfected patients with compensated cirrhosis and a Child-Pugh B score should be followed closely for the development of decompensation.

  30. RESUMEN • El estudio GESIDA 37/03 es una de las cohortes más grandes de pacientes infectados por VIH con cirrosis hepática. • Hasta el momento esta cohorte nos ha permitido caracterizar mejor la historia natural de la cirrosis hepática en esta población • Además hemos podido analizar los factores relacionados con la supervivencia y la primera descompensación. • Continuamos el seguimiento activo de esta cohorte (Dra. Marisa Montes)

  31. AGRADECIMIENTOS • M López-Diéguez, JF Pascual, M Montes, C Quereda, MA Von Wichmann, J Berenguer, C Tural, JM Miró, F Pulido, E Ortega, A Arranz, J González-García, Rosario Madero, Herminia Esteban

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