Intrahepatic Cholestasis of Pregnancy linked to NAFLD

Erica Monrose, MD

A recent study has found evidence suggesting a link between intrahepatic cholestasis of pregnancy (ICP) and nonalcoholic fatty liver disease (NAFLD).

The study, which was presented at Digestive Disease Week 2019 in San Diego, CA, found that women with intrahepatic cholestasis of pregnancy (ICP) are 5.7 times more likely to have a diagnosis of nonalcoholic fatty liver disease (NALFD).

The investigators conceived the possibility of the association from large population-based cohort studies, primarily in Europe, finding ICP occurring with other hepatobiliary conditions, notably hepatitis C and gallstones disease, recounted study lead author Erica Monrose, MD, of the Icahn School of Medicine at Mount Sinai, New York, NY.

“It would suggest that NAFLD patients who already have high levels of bile acids at baseline may be at higher risk for developing ICP during pregnancy, a condition characterized by a significant increase in bile acid levels," Monrose explained.

Monrose and colleagues conducted the retrospective case-control study at a single treatment center in the New York City health system between January and December 2017, identifying medical records for 149 patients with pregnancy complicated by ICP.

"Given the previously cited association between ICP and chronic liver disease, and the rise in diagnosis of NAFLD, we used a New York City based patient cohort with numerous NAFLD metabolic risk factors to assess whether a similar association exists between NAFLD and ICP, and whether providers should anticipate seeing a parallel increase in ICP prevalence," Monrose told MD Magazine^®.

A control group of 200 patients were matched by delivery year and had similar median age, nulliparity and prevalence of hepatitis C. Additionally, both groups had similar metabolic risk factors, including prevalence of obesity, hypertension, hemoglobin Alc greater than 5.5% and total cholesterol greater than 200mg/dl.

The investigators noted that the Hispanic women in their cohort were more likely to be diagnosed with ICP (2.53%) than non-Hispanic, and at a substantially higher rate than the national prevalence of 0.32%.

Monrose and colleagues reported that, compared to controls, the ICP group had higher median alanine aminotransferase (ALT), alkaline phosphatase, and total bilirubin levels. Authors also noted that ICP patients were more likely than controls to have a history of biliary disease (odds ratio [OR] 3.29, 95% confidence interval [CI] 1.39-7.80), evidence of steatosis on liver imaging (OR 4.69, CI 1.68-13.12), and a diagnosis of NAFLD (OR 5.7, CI 2.08-15.65).

Monrose commented on the importance of that guidance. "We feel strongly that based on our data, as well as the European data, that there is a role for follow-up of women with ICP postpartum and evaluation for other co-existent chronic liver disease, as well as follow-up postpartum until normalization of liver tests."

"ICP may be a 'symptom' of already existing liver disease that may not yet be diagnosed among at least a subset of these patients," she cautioned.

The study, Intrahepatic Cholestasis of Pregnancy (ICP) is Associated with Higher Prevalence of NAFLD: A Case-Control Study, was presented at DDW 2019 in San Diego, CA.