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Changes in Serum Cytokeratin 18 Levels Significantly Predict Changes inLiver Histology in Adults With Nonalcoholic Steatohepatitis: Results From thePivens TrialRaj Vuppalanchi, Ross B. Deppe, Katherine P. Yates, Megan Comerford, Howard C.Masuoka, Brent A. Tetri, Rohit Loomba, Elizabeth Brunt, David E. Kleiner, JamesTonascia, Naga P. Chalasani

Background: Previous cross-sectional studies have shown that serum levels of cytokeratinfragments (CK18) are associated with the presence of steatohepatitis in individuals withnonalcoholic fatty liver disease (NAFLD). However, it is unknown if serial serum CK18levels can predict longitudinal changes in liver histology in NAFLD. Aim: To determine thedegree to which changes in serum CK18 associate with changes in liver histology over a96-week period in adult patients with nonalcoholic steatohepatitis (NASH). Methods: SerumCK18 levels were measured at baseline and 16, 48, and 96 weeks in 231 of the 247adults with NASH who participated in the PIVENS trial which investigated the efficacy ofpioglitazone vs. vitamin E vs. placebo in non-diabetic individuals with histologically con-firmed NASH over a 96-week period. Liver biopsies at baseline and after 96 weeks oftreatment were centrally evaluated by the NASH CRN Pathology Committee. Multiple logistic(for categorical outcomes) and linear (for continuous outcome variables) regression modelswere used to determine the association between changes in histological features, ALT, and% collagen assessed by Sirius red staining, and change in CK18 levels, controlling for baselineCK18 levels and treatment group. Results: At baseline, CK18 levels among the 3 treatmentgroups were similar (placebo: 440± 350 U/L, vit E: 510± 350 U/L, and pioglitazone: 490±410 U/L). Compared to placebo, serum CK18 levels among individuals treated with vit Ewere reduced at week 16 (mean change from baseline -160± 300 vs. -50 ±380 U/L, p=0.02), week 48 (-220± 390 vs. -10± 370 U/L, p=0.009), and week 96 (-200± 400 vs. 30±400 U/L, p=0.009). Similarly, compared to placebo, serum CK18 levels among individualstreated with pioglitazone were reduced at week 16 (mean change from baseline -240 ± 390vs. -50± 380 U/L, p,=0.001), week 48 (-180± 370 vs. -10± 370 U/L, p=0.001, and week96 (-260 ±400 vs. 30 ± 400 U/L, p=0.001). Strong correlations were seen with change inCK18 levels and the primary histologic endpoint, resolution of NASH, and individualhistologic features of NASH (Table 1). In addition, change in CK18 levels strongly correlatedwith change in ALT levels (b=0.06, 95% CI: 0.04, 0.08; P,0.001).Percent collagen measure-ments were not related to change in CK18 (b=-0.17 %/100*U/L , 95% CI:-0.70, 0.37; P=0.54). Summary: (1) Compared to placebo, treatment with vit E or pioglitazone had significantreduction in serum CK18 levels. (2) Changes in serum CK18 correlated with histologicimprovement in non-diabetic adults with NASH treated with vitamin E or pioglitazone.Conclusion: Serum CK18 is a potential useful surrogate marker for detection of improvementin clinical trials.

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Predictors of Mortality in Individuals With Nonalcoholic Fatty Liver Disease(NAFLD) in the United States: Results From the Third National Health andNutrition Examination Survey (NHANES III)Kavitha Nutakki, Suthat Liangpunsakul, Naga P. Chalasani

Background: Recent data showed the increased in overall mortality in NAFLD patients, whencompared to general population. However, some studies reported the opposing results. Theplausible explanations are due to different length of follow up and methods to identifyNAFLD. It is also possible that not all NAFLD subjects pose the same risk for increasedmortality. We hypothesized that NAFLD is a serious condition but only in a subgroup ofindividuals who will suffer from increased mortality risk. Aim: To determine the overalland cause-specific mortalities in subjects with/without NAFLD, and to identify the riskfactors of mortality among NAFLD cases. Methods: We analyzed data from NHANESIIIfrom 1988-94 and the mortality follow-up data till 2006. NAFLD was defined by the presenceof ‘moderate/severe hepatic steatosis' by ultrasonography, in the absence of iron overload,hepatitis B/C, and excessive alcohol consumption. Controls were those without liver disease,normal ultrasound and liver tests. Survival analyses were conducted using log rank test.Univariate analysis was performed to identify predictors of mortality. The variables with aP value ,0.05 were entered into multivariate Cox Hazard model to identify the predictorsof overall/cause specific mortalities among NAFLD subjects. Results: 10,864 subjects consti-tuted our study cohort. 8,423 (mean age 42.3 ± 16.1 y, 56% female, and 39% White) werecontrols, whereas 2,441 (mean age 47.9 ± 15.5 y, 51% female, and 37%White) had NAFLD.1,193 (14%) controls and 501 (21%) NAFLD cases died during a median follow-up periodof 14.3 y (IQR: 12.8-15.8 years). Survival analyses between controls and NAFLD are shownin table below. The independent predictors of overall mortality in NAFLD cases were male

S-951 AASLD Abstracts

(HR 1.187, 95%CI 1.086-1.298), older age (HR 1.081, 95%CI 1.072-1.089), increased waistcircumference (HR 1.267, 95%CI 1.031-1.558), and low HDL (HR 1.116, 95%CI 1.020-1.221). Serum ALT and metabolic syndrome (MS) were not the predictors of mortality. Theindependent predictors of cardiovascular-related mortality among NAFLD were male (HR1.115, 95%CI 1.027-1.211), older age (HR 1.005, 95%CI 1.002-1.008), and low HDL(HR 1.101, 95%CI 1.014-1.197). Independent predictors of cancer-related mortality weremale(HR 1.100, 95%CI 1.014-1.193), older age (HR 1.007, 95%CI 1.004-1.010), low HDL(HR 1.113, 95%CI 1.026-1.208), and metabolic syndrome (HR 1.144, 95%CI 1.049-1.249).Summary: NAFLD subjects had higher overall mortality compared to controls. "NAFLDpatients at risk" for increased mortality are male, elderly, and those with high waist circumfer-ence and low HDL. Conclusion: More studies are needed to confirm various factors thatplace patients with NAFLD at risk for increased mortality, so these factors can be therapeuti-cally targeted to improve their prognosis.

608

Sustained Virological Response Prevents the Development of New Type 2Diabetes in Patients With Chronic Hepatitis CSarah M. Hyder, Sheela Krishnan, Kittichai Promrat

Background and Aims: Hepatitis C virus (HCV) infection is associated with insulin resistanceand has been shown to be an independent risk factor for development of type 2 diabetesin epidemiological studies. However, it is not know whether treatment of HCV infectioncorrelates with a decreased incidence of type 2 diabetes. Studies from Europe and Asiasuggest that a sustained virologic response (SVR) to treatment for HCV may lower the riskof type 2 diabetes. Methods: The Veterans Affairs Clinical Case Registry was used to identifyall patients with HCV infection without pre-existing diabetes who initiated anti-HCV therapybetween 1998 and 2007. The incidence of diabetes following antiviral treatment was calcu-lated in those who achieved sustained virological response (responders) and those who didnot successfully clear the infection (non-responders). We used multivariate Cox proportionalhazards analysis to identify additional variables implicated in the development of diabetesmellitus, including age, sex, race, body mass index, hypertension, coronary artery disease,cerebrovascular disease, peripheral vascular disease, and cirrhosis. Results: Of the 20,486chronic HCV patients without known diabetes who initiated antiviral therapy between 1998and 2007 with available results, 7, 856 patients (38%) achieved SVR and 12,630 patients(62%) did not achieve SVR. New onset diabetes mellitus was diagnosed in 902 (11.5%)responders and 2, 191 (17.3%) non-responders after a median follow up period of approxi-mately 5 years. In multivariate analysis controlling for known diabetes risk factors, SVR wasindependently associated with significantly decreased incidence of diabetes (hazard ratio0.76, 95% confidence interval 0.70-0.82, p-value ,.0001). In addition, increasing age, non-white race, hypertension, and cirrhosis were associated with an increased risk for new onsetdiabetes. Conclusions: SVR is associated with lower incidence of type 2 diabetes independentof other known diabetes risk factors. This finding strongly suggests the importance of HCVin the pathogenesis of diabetes in individuals at risk and supports significant benefit of HCVclearance on health outcome beyond liver-related morbidity and mortality.

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A Disease Severity Index Based on Dual Cholate Clearances and ShuntOutperforms Biopsy At Predicting Clinical Outcomes in Chronic Hepatitis CSteve M. Helmke, Jennifer DeSanto, Andrea Herman, Shannon Lauriski, Gregory T.Everson

Background and Aims. Dual cholate clearances and shunt were among the quantitative liverfunction tests that were most predictive of clinical outcomes in hepatitis C patients (Hepatol-ogy 2012; 55: 1019-1029). The aims of this study were to reanalyze archived cholate testingsamples using an improved validated LCMS method, and to derive a clinically useful diseaseseverity index (DSI). Methods. Cholate testing was performed at baseline in 224 chronicHCV patients (Ishak F2-6) enrolled in the HALT-C Trial, characterized by CTP scores of 5or 6 and no prior history of clinical complications. Patients were followed for up to 8.3years (mean ± SD, 4.9 ± 2.2 years) and clinical outcomes (n=54) were defined as CTPprogression, variceal bleeding, ascites, hepatic encephalopathy, and liver-related death. Oralcholate-2,2,4,4-d4 (40 mg) is taken up by enteric bile salt transporters directly into theportal vein and its clearance defines the Portal Hepatic Filtration Rate (HFR). IV cholate-24-13C (20mg) clearance defines the Systemic HFR. The ratio of Systemic to Portal HFRis a measure of the portal-systemic SHUNT. Labeled cholate clearances were determinedusing only 5 serum samples (Aliment Pharmacol Ther 2007; 26: 401-410) and an LCMSmethod validated to FDA guidelines for accuracy, precision, and freedom from interferences.Results. The relationships between outcomes and each of the cholate test results or theirLOGe transformations were analyzed by univariate Cox Proportional Hazard Regressions(Table 1). The test results with the highest Chi-Square values, SHUNT and LOGe PortalHFR, were used to generate an equation of the form DSI = A(SHUNT) - B(LOGe PortalHFR) + C. DSI scores ranged from ~10 for healthy controls to ~50 for the most severelydysfunctional liver disease patients. ROC curves (c-statistics: SHUNT 0.75, Portal HFR 0.84,DSI 0.83) were used to find optimum cutoffs for predicting outcomes. The prognosticperformance of cholate testing was compared to that of cirrhosis by biopsy (Table 2). Thehighest sensitivity, specificity, PPV, NPV, and balanced accuracy were all achieved by acholate test based DSI. Conclusions. Cholate tests could outperform biopsy diagnosedcirrhosis in predicting clinical outcomes in hepatitis C patients. The highest prognosticperformance was achieved by combining cholate test results into a DSI.Table 1. Cox Proportional Hazard Regression Analysis

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