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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 336 - 338
Correlation Of Aspartate Aminotransferase to Platelet Ratio Index and Child Tourrete Phughs Score in Patients with Chronic Liver Disease
 ,
 ,
 ,
1
Associate Professor, Department of General Medicine, Sri Siddhartha Medical College, Tumkur, Karnataka
2
Assistant Professor, Department of General Medicine, Sri Siddhartha Medical College, Tumkur, Karnataka
3
PG Resident, Department of General Medicine, Sri Siddhartha Medical College, Tumkur, Karnataka.
Under a Creative Commons license
Open Access
Received
Nov. 29, 2024
Revised
Jan. 3, 2025
Accepted
Jan. 20, 2025
Published
Jan. 25, 2025
Abstract

Introduction Liver disease, particularly alcoholic liver disease (ALD), is a significant global health issue, contributing to high morbidity and mortality rates. With increasing cases of liver cirrhosis, there is a growing need for simpler, cost-effective, and non-invasive diagnostic tools. The Aspartate Aminotransferase to Platelet Ratio Index (APRI) score has shown promise in assessing liver fibrosis, especially in resource-limited settings. This study explores the APRI score's utility in diagnosing and staging liver fibrosis in alcoholic liver cirrhosis patients in India. Objective To assess the effectiveness of the APRI score as a non-invasive marker for liver fibrosis and to correlate APRI score with the Child-Turcotte-Pugh (CTP) score. Methodology This cross-sectional study was conducted at Sri Siddhartha Medical College and Hospital, Tumkur, over 24 months, involving 102 patients with ultrasound-confirmed alcoholic liver cirrhosis. Data were collected through clinical, laboratory, and radiological assessments. The severity of liver dysfunction was evaluated using APRI and CTP scores. Statistical analysis was conducted, with significance set at p<0.05. Results 69.6% of participants had APRI scores >1, indicating advanced fibrosis, with a mean score of 3.034. APRI scores were significantly associated with CTP classification (p=0.024).  Conclusion The APRI score is an effective, non-invasive tool for assessing liver fibrosis in alcoholic liver cirrhosis, particularly in resource-limited settings. Its correlation with CTP score further denotes its use as a prognosticating factor.  Further longitudinal studies are needed to validate its prognostic value

Keywords
INTRODUCTION

Liver disease has emerged as a significant public health concern in India, accounting for a notable portion of global liver disease-related mortality. Specifically, it constituted 18.3% of the two million liver disease-related deaths worldwide in 20151. The prevalence of chronic liver diseases (CLDs) has been steadily rising since 1980, primarily due to increasing cases of cirrhosis and its complications, with alcohol-related liver disease being the leading cause of death, claiming approximately 2.5 million lives each year2. With limited treatment options like liver transplantation often hindered by high costs and donor shortages, accurately diagnosing cirrhosis has become crucial. Currently, liver biopsy remains the gold standard for diagnosis; however, it poses risks such as sample errors and complications, while non-invasive biochemical diagnostics are frequently complex and expensive3.

 

The pressing need for effective diagnostic tools is highlighted by the rising prevalence of cirrhosis and its serious complications, including hepatorenal syndrome and hepatic encephalopathy, which complicate patient management and outcomes1. Research has turned towards simpler parameters, with the AST to platelet ratio index (APRI) emerging as a promising non-invasive and cost-effective alternative for assessing significant fibrosis and cirrhosis. The APRI index combines readily available clinical data, making it a viable diagnostic tool that can be implemented in settings where traditional methods pose challenges due to invasiveness or cost3.

 

Despite the APRI index being validated in Western and some Asian populations, there is a notable lack of studies focusing on Indian demographics. This study aims to evaluate the APRI score as a bedside screening tool for liver cirrhosis specifically within the Indian population. By leveraging the simplicity and affordability of the APRI score, this research hopes to enhance early diagnosis and management of liver disease, potentially altering disease progression and mitigating the morbidity and mortality associated with liver-related conditions. The objective is to assess the APRI score as a non-invasive marker for liver cirrhosis in alcoholic patients, evaluating its correlation with clinical, biochemical, and radiological findings along with the Child-Turcotte-Pugh score

MATERIALS AND METHODS

This cross-sectional study was conducted over 24 months at Sri Siddhartha Medical College and Hospital, Tumkur, involving patients presenting to the outpatient department (OPD) or admitted to the General Medicine wards with symptoms, signs, and ultrasound evidence of alcoholic liver cirrhosis. Participants included patients aged 18 years and older, diagnosed with alcoholic liver cirrhosis through ultrasound, and willing to provide informed consent. Those with liver disorders of non-alcoholic origin, hematological disorders, or malignancies were excluded. A purposive sampling technique was used, and the required sample size, calculated based on specificity with an assumed prevalence of 50%, specificity of 85%, and precision of 10%, was determined to be 102 participants.

 

Data collection involved a detailed clinical history and comprehensive physical examination, focusing on complications of liver cirrhosis and signs of portal hypertension and liver cell failure. Diagnostic evaluations included liver function tests (LFT), complete blood count (CBC), renal function tests (RFT), stool occult blood tests, and ascitic fluid analysis. Severity assessments utilized the Child-Turcotte-Pugh (CTP) and APRI scoring systems. Data were recorded on a semi-structured proforma and analyzed using MS Excel (version 2019). Descriptive statistics, Chi-square tests, and independent t-tests were applied to assess associations, with a p-value of <0.05 considered statistically significant.

RESULTS

A total of 102 patients with ultrasound-proven liver cirrhosis due to alcoholic liver disease (ALD) were included in the study, recruited from the inpatient and outpatient departments of the General Medicine unit at SSMC, Tumkur. The demographic characteristics are presented in Table 1. Most participants (35, 34.3%) were aged between 41-50 years, followed by 26 (25.5%) in the 31-40 years age group. Only 8 (7.8%) were ≤30 years old, while 11 (10.8%) were above 60 years. Regarding gender distribution, males constituted a significant majority (93, 91.2%) compared to females (9, 8.8%).

 

The APRI (Aspartate Aminotransferase to Platelet Ratio Index) score was used as a non-invasive marker for cirrhosis diagnosis. Following WHO guidelines, an APRI score greater than 1.0 is considered a low cutoff for diagnosing cirrhosis (METAVIR F4). Among the 102 participants, 71 (69.6%) had an APRI score >1.0, with a mean score of 3.034, suggesting advanced liver fibrosis. In contrast, 31 participants (30.4%) had an APRI score ≤1.0, with a mean score of 0.642. The high proportion of participants with an APRI score >1.0 underscores the utility of this marker in identifying significant liver fibrosis and cirrhosis in patients with ALD.

 

Based on the Child-Turcotte-Pugh (CTP) score, which evaluates the severity of liver dysfunction, 80 participants (78.43%) were classified as Class C, indicating decompensated cirrhosis, while 22 (21.57%) were in Class B. None of the participants fell under Class A, emphasizing that the majority of cases represented severe disease. The average CTP score was 8.32 ± 0.84 for Class B and 11.59 ± 1.19 for Class C, reflecting significant hepatic impairment in the study cohort.

 

TABLE 1:

VARIABLES

CATEGORY

FREQUENCY

PERCENT

AGE (YEARS)

<=30

8

7.8

31-40

26

25.5

41-50

35

34.3

51-60

22

21.6

>60

11

10.8

SEX

MALE

93

91.2

FEMALE

9

8.8

 

TABLE 2:

 

VARIABLES

FREQUENCY

PERCENTAGE

CTP Class

A

0

0

B

22

21.57

C

80

78.43

APRI Score

< 1

71

69.6

>/= 1

31

30.4

 

TABLE 3:

Variable

APRI

Total

Chi-square

P-value*

<=1

>1

Age

<=30

2 (25.0%)

6 (75.0%)

8 (100%)

2.994

0.559

31-40

5 (19.2%)

21 (80.8%)

26 (100%)

41-50

11 (31.4%)

24 (68.6%)

35 (100%)

51-60

9 (40.9%)

13 (59.1%)

22 (100%)

>60

4 (36.4%)

7 (63.6%)

11 (100%)

Sex

MALE

24 (25.8%)

69 (74.2%)

   93 (100%)

10.477

0.001

FEMALE

7 (77.8%)

2 (22.2%)

9 (100%)

CTP Class

B

11 (50.0%)

11 (50.0%)

22 (100%)

5.098

0.024

C

20 (25.0%)

60 (75.0%)

80 (100%)

 

Table 3 presents the distribution of APRI scores in patients with alcoholic liver disease (ALD). APRI scores were categorized as ≤1 and >1 to evaluate their association with different demographic features and CTP score. A chi-square test was conducted to assess the statistical significance of these associations.

 

Age and sex showed distinct patterns in relation to APRI scores. While no significant association was observed between age groups and APRI scores (p=0.559), the sex distribution revealed a significant relationship (p=0.001). A higher proportion of males (74.2%) had APRI scores >1 compared to females (22.2%), indicating a more severe progression of liver disease in male patients. This highlights the potential influence of sex on the severity of liver fibrosis.

 

The CTP class showed a statistically significant relationship with APRI scores (p=0.024), with the majority of Class C participants (75%) having scores >1, underscoring the correlation between APRI and advanced liver disease severity.

DISCUSSION

Liver biopsy is the standard for staging liver cirrhosis, but non-invasive methods like the APRI score offer practical alternatives. This cross-sectional study evaluated the APRI score in patients with alcoholic liver cirrhosis, providing valuable insights. Among 102 participants, 69.6% had an APRI score >1, indicating significant fibrosis, with a mean score of 3.034 compared to 0.642 in those ≤1. Findings align with studies by Fallatah et al.4 and Oikonomou et al.5, where similar thresholds yielded high sensitivity (71% and 69.6%, respectively). Age distribution showed no significant association, but APRI >1 was highest among 31–40-year-olds, reflecting disease progression in midlife. Gender-wise, males had higher mean APRI scores, corroborating findings by Kurniawan et al.6

 

A significant positive correlation between APRI scores and Child-Turcotte-Pugh (CTP) class reinforces its prognostic utility. Similar associations were noted by Oikonomou et al.5 and Prakash BC and Shetty7. Additionally, Mahur et al.8 demonstrated correlations among APRI, MELD, and CTP scores, highlighting APRI as a simple, non-invasive predictor for complications and mortality in cirrhosis patients. These findings underscore the APRI score's clinical relevance in assessing disease severity and outcomes.

CONCLUSION

The APRI score is an effective, non-invasive marker for assessing liver fibrosis in cirrhosis, with strong correlations to clinical and laboratory parameters. It aids in monitoring disease severity and guiding management. Future longitudinal and case-control studies are recommended to validate its diagnostic accuracy and prognostic utility further.

 

Clinical Implications

This study highlights the APRI score's value in routine clinical practice for evaluating liver fibrosis in alcoholic cirrhosis. Its significant associations with clinical and biochemical parameters emphasize its utility as a non-invasive alternative to liver biopsy, facilitating better patient care while minimizing procedural risks.

 

Limitations

The study's cross-sectional design limits the assessment of APRI score progression over time. Observer variability in radiological findings and the absence of biopsy-confirmed diagnoses may impact precision. Larger, longitudinal studies with liver biopsy validation are needed to confirm the diagnostic accuracy of APRI in diverse populations. 

REFERENCES
  1. Ministry of Health and Family Welfare, India. (2016). National Health Policy.
  2. World Health Organization. (2015). Global Status Report on Alcohol and Health.
  3. Wai CT, Greenson JK, Fontana RJ, Kalbfleisch JD, Marrero JA, Conjeevaram HS, et al. (2003). The APRI score: A simple non-invasive index for predicting the presence of significant liver fibrosis in patients with chronic hepatitis C. Hepatology, 38(2), 518-526.
  4. Fallatah HI, Akbar HO, Qari YA, et al. APRI as a non-invasive marker for liver fibrosis. Liver Int. 2012;32(5):840-50.
  5. Oikonomou T, Goulis J, Zeglinas C, et al. Non-invasive markers in liver cirrhosis. Clin Gastroenterol Hepatol. 2015;13(12):2340-5.
  6. Kurniawan WD, Syam AF, Simadibrata M, et al. APRI scores and gender differences in cirrhosis. BMC Gastroenterol. 2018;18(1):2-9.
  7. Prakash BC, Shetty A. Role of APRI in hepatic encephalopathy assessment. Indian J Gastroenterol. 2020;39(3):212-8.
  8. Mahur H, Sharma A, Tiwari S. APRI, MELD, and Child-Pugh scores in cirrhosis prognosis. World J Hepatol. 2021;13(4):346-52.
  9. Suominen H, Kurppa K, Taina E. Radiological assessment in liver cirrhosis. Scand J Gastroenterol. 2017;52(6-7):746-51.
  10. Changchun L, He W, Zhang M. APRI and portal hypertension in cirrhosis. Hepatol Int. 2020;14(1):56-63.
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