twh liver centre uhn centre of excellence liver issues for the rhuematologist david wong, md...
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TWHLIVER
CENTRE
UHN centre of excellence
Liver issues for the Rhuematologist
David Wong, MDUniversity of Torontowww.torontoliver.ca
Disclosures (last 1 year):Research Studies: BMS, Gilead, Johnson & Johnson, VertexAdvisory Boards: Merck, Vertex
TWHLIVER
CENTRE
Objectives
To understand the sensitivity and specificity of Fibroscan and Fibrotest for liver monitoring in patients receiving MTX
To understand which patients to refer to a specialist
To consider which labs to monitor when screening for liver problems with DMARDS
TWHLIVER
CENTRE
Liver functionThe liver is not a filter
Liver is a factory for synthesis Food digested/absorbed portal vein Raw materials proteins, carbohydrates, fats Disposition
Hepatic vein to heart circulation Waste to bile stool
Liver function tests Delivery: platelet count (down with
hypersplenism) Synthesis: INR, Albumin Excretion: Bilirubin (conjugated)
TWHLIVER
CENTRE
0
20
40
60
80
100
0 20 40 60 80 100
% Fibrosis
% F
unct
ion
Fibrosis progression to symptoms
Cirrhosis
Symptoms
Platelets
INR
Albumin
Bilirubin
Imaging, Biopsy
TWHLIVER
CENTRE
Traditional test: Ultrasound
Ultrasound Small, coarse (rough), nodular Ascites Lobar redistribution Echogenic (fatty)
Limitations Later cirrhosis Tough to do in central obesity Expertise of Radiologist/Technician
TWHLIVER
CENTRE
Liver biopsy Safety
1/5: pain from bleed 1/5,000-1/10,000
BLEED Death Pneumothorax etc.
Time Hospital x hours Results in weeks
Error Inadequate sample Inadequate Expertise
Additional information Inflammation Fat
TWHLIVER
CENTRE
Occult cirrhosis can be uncovered by evaluation of unexplained
thrombocytopenia VA New York Harbor Health System 2008-
2010 N=497 not known to have cirrhosis/liver
disease N=382 analyzed N=112 assessed by GI or Hepatology
62 finished evaluation, 31 (50%) have cirrhosis 4 developed hepatoma Hepatitis C, ALD, NAFLD
APRI 1.41 in cirrhotics, 0.64 in non-cirrhotics
E Weiss et al. ACG 2012, P1353
TWHLIVER
CENTRE
Combined Clinical Tests: APRI & FIB-4
Cirrhosis Older individuals Platelets fall AST > ALT
(alcohol) Limitations
Must be calculated!
APRI
<0.5 is good >1.5 is advanced
FIB-4
<1.45 is good >2.35 is advanced
ASTxULN x 100Platelet count
Age x ASTPlatelet x ALT
TWHLIVER
CENTRE
FibrotestWikipedia or www.torontoliver.ca
Age Gender GGT Bilirubin
May be indirect a2-macroglobulin Haptoglobin
May be down Apo-Lipoprotein A1
L Castera et al. Gastroenterology 2005;128:343
TWHLIVER
CENTRE
Fibroscan
Accessing the liver Obesity Rib space Air (lungs, gut)
Probe size Small (S1 vs S2) Medium* Large
Time 2.5-3 minutes/scan
Maintenance 6-monthly
calibration Probe damage
Gel, cleaning
TWHLIVER
CENTRE
Performance characteristics
Laurant Castera et al. Gastroenterology 2005;128:343
APRIASTxULNx100Platelet
TWHLIVER
CENTRE
Fibrosis in PsoriaticsA: New users MTX (N=24), B: Biologics (N=15), C: Long term MTX
(N=10)
J Chladek et al. J Eur Acad Dermatol Venerol epub Aug 2012
PIIINP = N-terminal propeptide of collagen type III ; HA = Hyaluronic Acid
TWHLIVER
CENTRE
Recommendations for Methotrexate or Imuran
Baseline History
Metabolic syndrome Did you ever drink on a
regular or daily basis? Other history of liver
disease Labs
ALT, AST, ALP, CBC Ultrasound if abnormal
tests Especially if Plts <
150 HBsAg
Monitoring Labs
ALT, AST, ALP Look for rising numbers
over the first year that continue to go up rather than just fluctuate
CBC Look for falling platelet
count to < 150 Very concerned if Plts
< 150 and falling by >15% over 2 years
TWHLIVER
CENTRE
What to do for your cirrhotics
Stage Clinical Implication
1 Asymptomatic 10 year survival > 85-90%
2 Esophageal varices Screen with gastroscopy
3 History of variceal bleed Beta blockers lower risk
4 Ascites Synthesis failure: transplant
Hepatoma
At any stage Ultrasound surveillance (not AFP)
Plts < 150: suspect cirrhosis Plts < 100: likely will have varices Plts < 70: higher risk of renal failure (hepatorenal
syndrome) No NSAIDS (even with PPI) Tylenol <3-4g/day is much safer
Coffee may be good Alcohol in moderation may be good
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