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Liver issues for the Rhuematologist

Liver issues for the Rhuematologist. David Wong, MD University of Toronto www.torontoliver.ca. Disclosures (last 1 year): Research Studies: BMS, Gilead, Johnson & Johnson, Vertex Advisory Boards: Merck, Vertex. Objectives.

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Liver issues for the Rhuematologist

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  1. Liver issues for the Rhuematologist David Wong, MD University of Toronto www.torontoliver.ca Disclosures (last 1 year): Research Studies: BMS, Gilead, Johnson & Johnson, Vertex Advisory Boards: Merck, Vertex

  2. 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

  3. Do I have cirrhosis?

  4. 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)

  5. INR Bilirubin Platelets Albumin Fibrosis progression to symptoms Cirrhosis Symptoms Imaging, Biopsy

  6. 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

  7. 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

  8. Liver biopsies (H&E)

  9. 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

  10. Combined Clinical Tests: APRI & FIB-4 ASTxULN x 100 Platelet count • 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 Age x AST Platelet x ALT

  11. 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

  12. Fibrotest calculatorhttp://torontoliver.ca

  13. Fibrotest T Poynard et al. Comparative Hepatology 2004;3:8

  14. 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

  15. Fibroscan

  16. Performance characteristics APRI ASTxULNx100 Platelet Laurant Castera et al. Gastroenterology 2005;128:343

  17. Fibrosis in PsoriaticsA: New users MTX (N=24), B: Biologics (N=15), C: Long term MTX (N=10) PIIINP = N-terminal propeptide of collagen type III ; HA = Hyaluronic Acid J Chladek et al. J EurAcadDermatolVenerolepub Aug 2012

  18. Recommendations for Methotrexate or Imuran Baseline 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 • 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

  19. What to do for your cirrhotics • 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

  20. Questions?

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