Severe acute exacerbation in
chronic hepatitis B could lead to mortality in some patients unless timely
liver transplantation is performed. The baseline
bilirubin level has been reported to be an important prognostic factor for mortality. Here we conducted a prospective observational study to examine the clinical performance of this predictor.
METHOD: Of the 21 patients included, 9 had baseline
bilirubin >10 mg/dL. Four of these 9 patients (44.4%) eventually died, whereas all other patients survived. During the initial 2-week period, the change of
bilirubin was -1.2 mg/dl in the survivors, but was +8.05 mg/dl in the mortalities (P = 0.009). When this on-treatment factor was combined, 5 of the 21 patients had baseline
bilirubin > 10 mg/dL plus an increase of
bilirubin level at week-2. Of these 5 patients, 4 (80%) died. Thus, by combining the baseline and on-treatment
bilirubin levels, a positive predictive value of 80% and a negative predictive value of 100% could be achieved. Other significant on-treatment mortality predictors (at week-2) included higher international normalized ratio of prothrombin time (2.75 vs. 1.3, P = 0.004), higher model for
end-stage liver disease score (30 vs. 17, P = 0.006), lower
alpha-fetoprotein level (36.3 vs. 459.6 ng/mL, P = 0.039), and more rapid deterioration of the estimated glomerular filtration rate (eGFR) (P = 0.008). Interestingly, during the course, deterioration of eGFR was statistically significant in
entecavir-treated (P = 0.028), but not in
telbivudine-treated patients. Additionally, the patients treated with
telbivudine had significant increase in serum
alpha-fetoprotein (27.9 to 191.9 ng/ml, P = 0.046) in the first 2 weeks, whereas the corresponding feature was not found in those treated with
entecavir (P = 0.139).
CONCLUSIONS: In this prospective observational study, we discovered that the baseline and on-treatment
bilirubin levels should be combined to achieve a better predictive value.
Telbivudine might have a renoprotective effect in addition to its efficacy in viral suppression in patients with severe acute exacerbation.