Interpreting Your Test Results

1. Interpreting Your Test Results William Carey, MD MACG FAASLD PSC Partners Seeking A Cure June 23, 2017 3PM – 4PM

2. Where to learn more http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/guide-to-common-liver-tests/

3. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/cirrhosis-cholangitis-other-cholestatic-liver-disease/http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/cirrhosis-cholangitis-other-cholestatic-liver-disease/

4. Within the liver cell the enzyme alkaline phosphatase is located close to the bile cannaliculus

5. Patterns of Liver Injury

6. Liver Enzymes • Sensitive for hepatic injury • Not very specific to identify the cause of liver injury

7. Non Hepatic Sources of Select Lab Tests

8. Acute vs. Chronic • 6 months duration • New onset elevation of LFT in a chronic condition. “Acute on chronic liver disease”

9. Wilson Disease HCV, HBV, AIH

10. Why Is My Bilirubin Elevated?

11. Bilirubin Nomenclature

12. Disease That Principally Affect The Bile Ducts(Cholestatic Liver Disease)

13. Cholangiography (ERCP)

14. Cholangiography (ERCP/MRCP)

15. More than one liver disease can occur in the same person !!! Commonest Liver Diseases USA 2017 • Fatty Liver Disease • Hepatitis C

16. What Is Fatty Liver?

18. Hepatitis C

19. Tests of Hepatic Fibrosis

20. Complications of Liver Biopsy • Pain • (84% of all biopsies) • Bleeding • (clinically significant*-1:2,500-1:10,000) • Death • Mostly due to bleeding • Reported in 1:10,000 *Requiring transfusion, intervention or hospitalization

21. Evolution of Diagnosis of Cirrhosis From Biopsy to Elastography

22. Elastography Fibroscan (Echosens) ARFI (Siemens) MRI elastography

23. M/S to kPa unitsE=3xV2 F2: Cut-off 1.34 m/s 3 x (1.34)^2 = E = 5.4 kPa F3: Cut-off 1.55 m/s3 x (1.55)^2 = E = 7.2 kPa F4: Cut-off 1.80 m/s 3 x (1.83)^2 = E = 10.04 kPa

24. Compensated Advanced Chronic Liver Disease (Cirrhosis) • TE [kPA]values: • < 10 in the absence of other known clinical signs RULES OUT cirrhosis • 10 – 15 Suggestive of cirrhosis • > 15 highly suggestive of cirrhosis

25. Serum Fibrosis Biomarkers Cales et al.Liver Inter 2008; 28:1352 Degos et al. J Hepatol 2010; 53: 1013 Zarski et al. J Hepatol 2012: 56:55 Castera et al. Gastro 2005; 128: 343

27. Non Invasive Assessment Fatty Liver

28. NAFLD Fibrosis Score The most studied and validated biomarker What is it: Limitations: performs best in Caucasians NAFLD Fibrosis Score = -1.65+0.037 x age(yr) + 0.094 x BMI + 1.13 x IFG/diabetes [yes=1; no = 0) + 0.99 x AST/ALT ratio – 0.013 x platelet count (x 10^9/L) – 0.66 x albumin (g/dl)

29. NAFLD Fibrosis Score http://nafldscore.com/ Angulo et al. Hepatology2007;45:846

30. Serum Fibrosis Biomarkers APRI SCORE APRI score greater than 1.0 has a sensitivity of 76% and specificity of 72% for predicting cirrhosis. APRI score greater than 0.7 had a sensitivity of 77% and specificity of 72% for predicting significant hepatic fibrosis. APRI score calculator: www.thecalculator.co/health/AST-to-Platelet-Ratio-Index-APRI-Calculator-700.html Comparing patented vs. APRI scores AUROC values for significant fibrosis – no difference in performance Lin ZH, Xin YN, Dong QJ, et al. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatology. 2011;53:726-36.

31. Cirrhosis: Know the Score

34. Serum Sodium Concentration and the Relative Risk of Death after Adjustment for the MELD Score MELD NA and UNOS Kim WR et al. N Engl J Med 2008;359:1018-1026

35. Summary • Liver tests usually need to be interpreted as a pattern • Blood tests can identify with certainty hepatitis B, C and some other conditions • PSC cannot be accurately diagnosed by blood tests. • MRCP has replaced ERCP to a large extent • Liver biopsy is used much less frequently • When cirrhosis is present, Childs Pugh and MELD gauge remaining liver reserves

36. Thank you