Hepatic involvement and portal hypertension predict mortality in chronic granulomatous disease

Abstract

Background & aims: Chronic granulomatous disease (CGD) is a rare genetic disorder, predisposing affected individuals to recurrent infectious complications and shortened survival. Liver involvement in CGD includes vascular abnormalities, which may lead to noncirrhotic portal hypertension.

Methods: To evaluate the impact of noncirrhotic portal hypertension on survival in CGD, all records from 194 patients followed up at the National Institutes of Health with CGD were reviewed. Cox proportional hazards regression was used to determine factors associated with mortality.

Results: Twenty-four patients died, all from infectious complications. By Cox regression, factors associated with mortality were as follows: (1) decreases in platelet count (>9000/microL/y; hazard ratio, 4.7; P = .007), (2) alkaline phosphatase level increases (>0.25/y; hazard ratio, 4.5; P = .01) and (3) history of liver abscess (hazard ratio, 3.1; P = .03). By regression analysis, decreasing platelet count was associated with increasing portal vein diameter, splenomegaly, increased serum immunoglobulin G level, and increasing number of alanine aminotransferase increases; greater number of alkaline phosphatase level increases and abscess were both associated with increasing age and number of infections. Prospective evaluation revealed increased hepatic-venous pressure gradients in 2 patients with progressive thrombocytopenia, suggestive of portal hypertension.

Conclusions: These data suggest mortality in patients with CGD is associated with the development of noncirrhotic portal hypertension, likely owing to injury to the microvasculature of the liver from repeated systemic and hepatic infections. The slope of decline in platelet count may be a useful measure of progression of portal hypertension over time. Furthermore, the data illustrate the potential independent effect of portal hypertension on clinical outcome outside the setting of cirrhosis.

Figure 1

Platelet slopes from representative patients who a) died and b) survived to end of follow-up.

Figure 2

Estimate of the survival function for each of the determinants of mortality based on the Cox proportional hazards model. The curves compare the survival estimates for patients with and without a) declining platelet slope b) ALP elevations and c) a history of liver abscess. Each curve is adjusted for all factors in the multivariable Cox model. d) This figure compares the survival function for patients with all three determinants of mortality with that for patients with none of these factors.

Figure 2

Estimate of the survival function for each of the determinants of mortality based on the Cox proportional hazards model. The curves compare the survival estimates for patients with and without a) declining platelet slope b) ALP elevations and c) a history of liver abscess. Each curve is adjusted for all factors in the multivariable Cox model. d) This figure compares the survival function for patients with all three determinants of mortality with that for patients with none of these factors.

Figure 2

Estimate of the survival function for each of the determinants of mortality based on the Cox proportional hazards model. The curves compare the survival estimates for patients with and without a) declining platelet slope b) ALP elevations and c) a history of liver abscess. Each curve is adjusted for all factors in the multivariable Cox model. d) This figure compares the survival function for patients with all three determinants of mortality with that for patients with none of these factors.

Figure 2

Estimate of the survival function for each of the determinants of mortality based on the Cox proportional hazards model. The curves compare the survival estimates for patients with and without a) declining platelet slope b) ALP elevations and c) a history of liver abscess. Each curve is adjusted for all factors in the multivariable Cox model. d) This figure compares the survival function for patients with all three determinants of mortality with that for patients with none of these factors.