Maddrey, GAHS, Lille – Alkoholni hepatitis
Ocena resnosti in prognoze alkoholnega hepatitisa
Dodatne informacije
Opozorilo
Orodje je namenjeno zgolj v izobraževalne namene in ne predstavlja strokovnega nasveta ali nadomestka za strokovni nasvet. Orodja ni dovoljeno uporabljati za podajo medicinske diagnoze in/ali medicinsko zdravljenje.
General description
Alcohol-associated liver disease (ALD) is a pertinent public health issue, associated with nearly 6 % of all deaths globally. Alcoholic hepatitis is a severe syndrome of ALD that can be responsive to treatment with glucocorticoids. Different prognostic scores have been developed to identify high risk patients that can potentially benefit from glucocorticoid therapy; these include the (modified) Maddrey's discriminant function (mDF), Glasgow alcoholic hepatitis score (GAHS) and Lille Model for Alcoholic Hepatitis.
The mDF calculation is based on bilirubin and prothrombin time values whereas the GAHS is derived from five variables independently associated with outcome (age, serum bilirubin, blood urea, prothrombin time, and white blood cell count). Patients with an mDF ≥ 32 and a GAHS ≥ 9 were shown to have poor short-term prognosis which could be improved with glucocorticoid treatment.
The Lille score is primarily used to assess treatment response and can therefore help inform decisions to either discontinue glucocorticoid therapy after 7 days or prolong it to 28 days. A Lille score of ≥ 0.45 was shown to indicate non-response to glucocorticoids.
The mDF, the GAHS and the Lille score are endorsed by the 2018 EASL (European Association for the Study of the Liver) clinical practice guidelines on the management of alcohol-related liver disease.
Alcohol-associated liver disease (ALD) is a pertinent public health issue, associated with nearly 6 % of all deaths globally. Alcoholic hepatitis is a severe syndrome of ALD that can be responsive to treatment with glucocorticoids. Different prognostic scores have been developed to identify high risk patients that can potentially benefit from glucocorticoid therapy; these include the (modified) Maddrey's discriminant function (mDF), Glasgow alcoholic hepatitis score (GAHS) and Lille Model for Alcoholic Hepatitis.
The mDF calculation is based on bilirubin and prothrombin time values whereas the GAHS is derived from five variables independently associated with outcome (age, serum bilirubin, blood urea, prothrombin time, and white blood cell count). Patients with an mDF ≥ 32 and a GAHS ≥ 9 were shown to have poor short-term prognosis which could be improved with glucocorticoid treatment.
The Lille score is primarily used to assess treatment response and can therefore help inform decisions to either discontinue glucocorticoid therapy after 7 days or prolong it to 28 days. A Lille score of ≥ 0.45 was shown to indicate non-response to glucocorticoids.
The mDF, the GAHS and the Lille score are endorsed by the 2018 EASL (European Association for the Study of the Liver) clinical practice guidelines on the management of alcohol-related liver disease.
Version: 1. 1. 2022
Formula for mDF
Modified Discriminant Function = 4.6 × (Patients prothrombin time [s] - Normal prothrombin time [s]) + Serum bilirubin [µmol/L]/17.1
Formula for GAHS
Glasgow Alcoholic Hepatitis Score is calculated by summing points.
1 point is given for age < 50 years, white blood cell count < 15 × 10⁹/L, urea < 5 mmol/L (30 mg/dL), prothrombin time ratio < 1.5 and serum bilirubin < 125 µmol/L.
2 points are given for age ≥ 50 years, white blood cell count ≥ 15 × 10⁹/L, urea ≥ 5 mmol/L (30 mg/dL), Prothrombin time ratio 1.5–2.0 and serum bilirubin 125–250 µmol/L.
3 points are given for prothrombin time ratio > 2.0 and serum bilirubin > 250 µmol/L.
1 point is given for age < 50 years, white blood cell count < 15 × 10⁹/L, urea < 5 mmol/L (30 mg/dL), prothrombin time ratio < 1.5 and serum bilirubin < 125 µmol/L.
2 points are given for age ≥ 50 years, white blood cell count ≥ 15 × 10⁹/L, urea ≥ 5 mmol/L (30 mg/dL), Prothrombin time ratio 1.5–2.0 and serum bilirubin 125–250 µmol/L.
3 points are given for prothrombin time ratio > 2.0 and serum bilirubin > 250 µmol/L.
Formula for Lille score
Lille score = e-R /(1 + e-R)
R = 3.19 - 0.101 × (age [years]) + 0.147 × (albumin day 0 [g/L]) + 0.0165 × (difference in bilirubin levels between day 0 and day 7 in [µmol/L]) - 0.206 × (renal insufficiency) - 0.0065 × (bilirubin day 0 in µmol/L) - 0.0096 × (prothrombin time [s] or INR)
Renal insufficiency (defined as serum creatinine above 115 µmol/l (1.3 mg/dL) or creatinine clearance less than 40 ml/min) is rated 0 if absent and 1 if present.
R = 3.19 - 0.101 × (age [years]) + 0.147 × (albumin day 0 [g/L]) + 0.0165 × (difference in bilirubin levels between day 0 and day 7 in [µmol/L]) - 0.206 × (renal insufficiency) - 0.0065 × (bilirubin day 0 in µmol/L) - 0.0096 × (prothrombin time [s] or INR)
Renal insufficiency (defined as serum creatinine above 115 µmol/l (1.3 mg/dL) or creatinine clearance less than 40 ml/min) is rated 0 if absent and 1 if present.
Result ranges for mDF and GAHS
When mDF < 32 and GAHS < 9 no specific therapy is required.
When mDF ≥ 32 or GAHS ≥ 9 treatment with Prednisolone 40 mg/day ± N-acetylcysteine and further assessment of treatment response at day 7 by calculating Lille score is recommended.
When mDF ≥ 32 or GAHS ≥ 9 treatment with Prednisolone 40 mg/day ± N-acetylcysteine and further assessment of treatment response at day 7 by calculating Lille score is recommended.
Result ranges for Lille score
When Lille score < 0.45 continuation of treatment with Prednisolone 40 mg/day ± N-acetylcysteine for 28 days is recommended.
When Lille score ≥ 0.45 discontinuation of treatment (particularly in null responders (Lille score ≥ 0.56)) and assessment for early liver transplantation in highly selected patients is recommended.
When Lille score ≥ 0.45 discontinuation of treatment (particularly in null responders (Lille score ≥ 0.56)) and assessment for early liver transplantation in highly selected patients is recommended.
References
Maddrey, W C et al. “Corticosteroid therapy of alcoholic hepatitis.” Gastroenterology vol. 75,2 (1978): 193-9.
Carithers, R L Jr et al. “Methylprednisolone therapy in patients with severe alcoholic hepatitis. A randomized multicenter trial.” Annals of internal medicine vol. 110,9 (1989): 685-90. doi:10.7326/0003-4819-110-9-685
Forrest, E H et al. “Analysis of factors predictive of mortality in alcoholic hepatitis and derivation and validation of the Glasgow alcoholic hepatitis score.” Gut vol. 54,8 (2005): 1174-9. doi:10.1136/gut.2004.050781
Louvet, Alexandre et al. “The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids.” Hepatology (Baltimore, Md.) vol. 45,6 (2007): 1348-54. doi:10.1002/hep.21607
European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu. and European Association for the Study of the Liver. “EASL Clinical Practice Guidelines: Management of alcohol-related liver disease.” Journal of hepatology vol. 69,1 (2018): 154-181. doi:10.1016/j.jhep.2018.03.018
Verzija
1
O tem orodju
Alcohol-associated liver disease (ALD) is a pertinent public health issue, associated with nearly 6 % of all deaths globally. Alcoholic hepatitis is a severe syndrome of ALD that can be responsive to treatment with glucocorticoids. Different prognostic scores have been developed to identify high risk patients that can potentially benefit from glucocorticoid therapy; these include the (modified) Maddrey's discriminant function (mDF), Glasgow alcoholic hepatitis score (GAHS) and Lille Model for Alcoholic Hepatitis.
The mDF calculation is based on bilirubin and prothrombin time values whereas the GAHS is derived from five variables independently associated with outcome (age, serum bilirubin, blood urea, prothrombin time, and white blood cell count). Patients with an mDF ≥ 32 and a GAHS ≥ 9 were shown to have poor short-term prognosis which could be improved with glucocorticoid treatment.
The Lille score is primarily used to assess treatment response and can therefore help inform decisions to either discontinue glucocorticoid therapy after 7 days or prolong it to 28 days. A Lille score of ≥ 0.45 was shown to indicate non-response to glucocorticoids.
The mDF, the GAHS and the Lille score are endorsed by the 2018 EASL (European Association for the Study of the Liver) clinical practice guidelines on the management of alcohol-related liver disease.
The mDF calculation is based on bilirubin and prothrombin time values whereas the GAHS is derived from five variables independently associated with outcome (age, serum bilirubin, blood urea, prothrombin time, and white blood cell count). Patients with an mDF ≥ 32 and a GAHS ≥ 9 were shown to have poor short-term prognosis which could be improved with glucocorticoid treatment.
The Lille score is primarily used to assess treatment response and can therefore help inform decisions to either discontinue glucocorticoid therapy after 7 days or prolong it to 28 days. A Lille score of ≥ 0.45 was shown to indicate non-response to glucocorticoids.
The mDF, the GAHS and the Lille score are endorsed by the 2018 EASL (European Association for the Study of the Liver) clinical practice guidelines on the management of alcohol-related liver disease.
