This cohort from across the UK is older than other multicentre AIH cohorts. One-fifth had decompensation or MELD >15. Diagnosis was delayed in 19%, diagnostic testing was incomplete in one-third and rosettes and emperipolesis were infrequently reported.
BackgroundInternational guidelines recommend coeliac serology in iron deficiency anaemia, and duodenal biopsy for those tested positive to detect coeliac disease. However, pre-endoscopy serology is often unavailable, thus committing endoscopists to take routine duodenal biopsies. Some endoscopists consider duodenal biopsy mandatory in anaemia to exclude other pathologies. We hypothesise that using a point of care test at endoscopy could fill this gap, by providing rapid results to target anaemic patients who require biopsies, and save costs by biopsy avoidance. We therefore assessed three key aspects to this hypothesis: 1) the availability of pre-endoscopy serology in anaemia; 2) the sensitivities and cost effectiveness of pre-endoscopy coeliac screening with Simtomax in anaemia; 3) whether other anaemia-related pathologies could be missed by this targeted-biopsy approach.MethodsGroup 1: pre-endoscopy serology availability was retrospectively analysed in a multicentre cohort of 934 anaemic patients at 4 UK hospitals. Group 2: the sensitivities of Simtomax, endomysial and tissue-transglutaminase antibodies were compared in 133 prospectively recruited patients with iron deficiency anaemia attending for a gastroscopy. The sensitivities were measured against duodenal histology as the reference standard in all patients. The cost effectiveness of Simtomax was calculated based on the number of biopsies that could have been avoided compared to an all-biopsy approach. Group 3: the duodenal histology of 153 patients presenting to a separate iron deficiency anaemia clinic were retrospectively reviewed.ResultsIn group 1, serology was available in 361 (33.8 %) patients. In group 2, the sensitivity and negative predictive value (NPV) were 100 % and 100 % for Simtomax, 96.2 % and 98.9 % for IgA-TTG, and 84.6 % and 96.4 % for EMA respectively. In group 3, the duodenal histology found no causes for anaemia other than coeliac disease.ConclusionSimtomax had excellent diagnostic accuracy in iron deficiency anaemia and was comparable to conventional serology. Duodenal biopsy did not identify any causes other than coeliac disease for iron deficiency anaemia, suggesting that biopsy avoidance in Simtomax negative anaemic patients is unlikely to miss other anaemia-related pathologies. Due to its 100 % NPV, Simtomax could reduce unnecessary biopsies by 66 % if only those with a positive Simtomax were biopsied, potentially saving £3690/100 gastroscopies.Trial registrationThe group 2 study was retrospectively registered with clinicaltrials.gov. Trial registration date: 13th July 2016; Trial registration number: NCT02834429.
Background
With few data regarding treatment and outcome of patients with AIH outside of large centres we present such a study of patients with AIH in 28 UK hospitals of varying size and facilities.
Methods
Patients with AIH were identified in 14 University and 14 District General hospitals; incident cases during 2007–2015 and prevalent cases, presenting 2000–2015. Treatment and outcomes were analysed.
Results
In 1267 patients with AIH, followed up for 3.8 (0–15) years, 5‐ and 10‐year death/transplant rates were 7.1 ± 0.8% and 10.1 ± 1.3% (all‐cause) and 4.0 ± 0.6% and 5.9 ± 1% (liver related) respectively. Baseline parameters independently associated with death/transplantation for all causes were: older age, vascular/respiratory co‐morbidity, cirrhosis, decompensation, platelet count, attending transplant centre and for liver related: the last four of these and peak bilirubin. All‐cause and liver‐related death/transplantation was independently associated with: non‐treatment with corticosteroids, non‐treatment with a steroid‐sparing agent (SSA), non‐treatment of asymptomatic or non‐cirrhotic patients and initial dose of Prednisolone >35 mg/0.5 mg/kg/day (all‐cause only), but not with type of steroid (Prednisolone vs. Budesonide) or steroid duration beyond 12 months. Subsequent all‐cause and liver‐death/transplant rates showed independent associations with smaller percentage fall in serum ALT after 1 and 3 months, but not with failure to normalise levels over 12 months.
Conclusions
We observed higher death/transplant rates in patients with AIH who were untreated with steroids (including asymptomatic or non‐cirrhotic subgroups), those receiving higher Prednisolone doses and those who did not receive an SSA. Similar death/transplant rates were seen in those receiving Prednisolone or Budesonide, those continuing steroids after 12 months and patients attaining normal ALT within 12 months versus not.
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