The use of transient elastography in the management of chronic hepatitis B

Fibrosis evolution in chronic hepatitis B e antigen-negative patients across a 10-year interval

The degree of liver fibrosis in chronic hepatitis B (CHB) infection influences outcome and management. Existing data describing the long-term dynamic changes of liver fibrosis are limited. This study aimed to evaluate the evolution of liver fibrosis in CHB across a 10-year period. CHB patients with liver stiffness measurement (LSM) by transient elastography 10 years ago were recruited for follow-up LSM. Fibrosis stages were classified according to EASL-ALEH guidelines. Fibrosis progression/regression was arbitrarily defined as ≥1 fibrosis stage change from baseline. A total of 459 hepatitis B e antigen (HBeAg)-negative patients (224 untreated, 235 treated with nucleos(t)ide analogues [NAs]) were recruited. The mean age at baseline LSM was 41.7 ± 9.0 years (56.2% male). Over 10 years, the proportion of patients with advanced fibrosis/cirrhosis significantly reduced from 16.3% to 5.7% (P < 0.001). Fibrosis progression and regression were observed in 8.7% and 37.5%, respectively. No treatment with NAs (OR 2.259, 95% confidence interval [CI]: 1.032-4.945), metabolic syndrome (OR 4.379, 95% CI: 1.128-16.999) and hepatic steatosis (OR 7.799, 95% CI: 2.271-26.776) was associated with fibrosis progression. Liver stiffness decline demonstrated positive correlation with the time after HBsAg seroclearance (r = -0.50, P < 0.001). Median liver stiffness was higher both at baseline (14.0 vs 6 kPa, P < 0.001) and 10 years (9.1 vs 4.9 kPa, P < 0.001) in patients with cirrhosis-related complications/hepatocellular carcinoma compared with those without. In conclusion, CHB-related liver fibrosis changed dynamically across 10 years. Metabolic syndrome and hepatic steatosis were associated with fibrosis progression, while antiviral therapy was associated with fibrosis regression. Patients with HBsAg seroclearance demonstrated time-dependent decline in liver stiffness.

Non-ALT biomarkers for markedly abnormal liver histology among Chinese persistently normal alanine aminotransferase-chronic hepatitis B patients

AIM

To determine incidence and clinical biomarkers of marked necroinflammation and fibrosis characteristics among chronic hepatitis B (CHB) patients with persistently normal alanine aminotransferase (PNALT).

METHODS

Liver biopsy was performed on 115 CHB patients with PNALT. Necroinflammation and fibrosis were graded by the Knodell histologic activity index and the Ishak fibrosis score, respectively. Correlations between the available clinical parameters and necroinflammation and fibrosis were analysed.

RESULTS

Marked necroinflammation (Knodell activity index ≥ 7) and fibrosis (Ishak fibrosis score ≥ 3) were found in 36.5% and 15.5% of CHB patients with PNALT, respectively. Following a univariate logistic regression analysis, multiple logistic regression analysis indicated that aspartate transaminase (AST) (AUROC = 0.852, cut-off value = 22.5 U/L) serves as an independent predictor of notable liver inflammation, while platelet (PLT) count (AUROC = 0.905, cut-off value = 171.5 ×10⁹/mL) and gamma-glutamyl transpeptidase (GGT) (AUROC = 0.909, cut-off value = 21.5 U/L) level serve as independent predictors of notable liver fibrosis.

CONCLUSION

A considerable proportion of marked histological abnormalities existed in our cohort, who will benefit from optimal therapeutic strategies administered according to predictive indication by AST, PLT and GGT levels.

Ultrasound shear wave elastography and liver fibrosis: A Prospective Multicenter Study

AIM

To assess the accuracy of shear wave elastography (SWE) alone and in combination with aminotransferase platelet ratio index (APRI) score in the staging of liver fibrosis.

METHODS

A multicenter prospective study was conducted to assess the accuracy of SWE (medians) and APRI to predict biopsy results. The analysis focused on distinguishing the different stages of liver disease, namely, F0 from F1-4, F0-1 from F2-4, F0-2 from F3-4 and F0-3 from F4; F0-F1 from F2-F4 being of primary interest. The area under the receiver operating characteristic (AUROC) curve was computed using logistic regression model. The role of age, gender and steatosis was also assessed.

RESULTS

SWE alone accurately distinguished F0-1 from F2-4 with a high probability. The AUROC using SWE alone was 0.91 compared to 0.78 for using the APRI score alone. The APRI score, when used in conjunction with SWE, did not make a significant contribution to the AUROC. SWE and steatosis were the only significant predictors that differentiated F0-1 from F2-4 with an AUROC of 0.944.

CONCLUSION

Our study validates the use of SWE in the diagnosis and staging of liver fibrosis. Furthermore, the probability of a correct diagnosis is significantly enhanced with the addition of steatosis as a prognostic factor.

HBsAg Level as Predictor of Liver Fibrosis in HBeAg Positive Patients With Chronic Hepatitis B Virus Infection

BACKGROUND AND AIMS

Preliminary data suggests lower serum hepatitis B surface antigen level is associated with more severe liver fibrosis in HBeAg positive patients. We evaluated the association of HBsAg level with biochemical, virological, and histological features in asymptomatic patients with chronic HBV infection.

METHODS

HBsAg levels were measured at baseline in 481 asymptomatic, treatment naive patients with chronic HBV infection. Subjects were followed-up prospectively (median, 12; range, 8-36 months). Phases of HBV infection were defined after regular monitoring of HBV-DNA and transaminases. Liver histology was scored using the METAVIR system.

RESULTS

HBeAg positive (n, 126) patients were significantly younger than HBeAg negative (n, 355), median age 26 vs 30 years; P < 0.01. HBV genotype could be determined in 350 patients, 240 (68.57%) had genotype D and 100 (28.57%) had genotype A. HBsAg level had modest correlation with serum HBV DNA(r = 0.6 vs 0.4 in eAg positive & negative respectively). HBeAg + ve patients with fibrosis score ≥ F2 showed significantly lower median serum HBsAg levels and serum HBV DNA levels compared with patients with F0-F1 score (median, range; 4.51, 2.99-6.10 vs 5.06, 4.13-5.89, P < 0.01) and (8.39, 3.85-10.60, P < 0.01) respectively. Significant inverse correlation of HBsAg level was found with liver fibrosis in eAg positive group (r = -0.76; P < 0.001). HBsAg level cut off value 4.7 log10 IU/ml predicted moderate to advance fibrosis (F ≥ 2) with 92% sensitivity, 85% specificity & 91% negative predictive value.

CONCLUSION

Lower HBsAg level might reflect the status of advanced liver fibrosis in HBeAg positive chronic hepatitis B subjects.

Performance of transient elastography assessing fibrosis of single hepatitis B virus infection: a systematic review and meta-analysis of a diagnostic test

INTRODUCTION

Transient elastography has good diagnostic accuracy for predicting fibrosis and cirrhosis related to hepatitis B virus. However, the enrolled subjects in some studies have also included chronic hepatitis B patients with chronic hepatitis C coinfection or other etiologies of liver diseases. This might under- or overestimate the role of transient elastography in chronic hepatitis B patients.

METHODS

A systematic review was conducted on records in PubMed, EMBASE and the Cochrane Library electronic databases until 31 December 2013. We systematically assessed the effectiveness and accuracy of transient elastography for predicting the fibrosis and cirrhosis of the single hepatitis B virus. The questionnaire for quality assessment of diagnostic accuracy studies was used.

RESULTS

In this meta-analysis, out of 257 articles evaluated for eligibility, 165 satisfied the predetermined inclusion criteria for meta-analysis. Eventually, our final data set for the meta-analysis contained 19 studies. The areas under the summary receiver-operating characteristic curve for transient elastography of significant fibrosis and cirrhosis were 0.8225 and 0.9108, respectively. The pooled diagnostic odds ratios for transient elastography of significant fibrosis and cirrhosis were 11.19 (95 % CI 6.63-18.89) and 26.87 (95 % CI 17.88-40.38), respectively. In Europe, the areas of significant fibrosis and cirrhosis were 0.803 and 0.905; those in Asia were 0.871 and 0.914, respectively.

CONCLUSIONS

Based on this meta-analysis we claim that liver stiffness measurement using transient elastography has good diagnostic accuracy for predicting single hepatitis B virus-related significant fibrosis and cirrhosis, especially in Asian populations.

Challenges in the management of chronic HBV infection in West Africa: The clinician's perspective

BACKGROUND

Hepatitis B infection has become a public health issue in recent years. Approximately 350 million of the world's population are chronically infected reaching endemic proportions in West Africa. Guidelines for treatment are continuously improving but are becoming more complex.

AIM

To determine the challenges hepatologists experience in the management of patients with chronic hepatitis B.

METHODS

This was a cross-sectional descriptive study conducted among hepatologists in West Africa during a regional hepatitis conference in 2013.

RESULTS

Forty-six hepatologists completed the questionnaire. When evaluating a patient for chronic hepatitis B, the preferred investigations were: LFT (100%); abdominal ultrasound (93.5%); HBeAg (93.5%); HBV DNA (78%); HBsAg measure (22%); HBV genotype (15.2%); and liver biopsy (34.8%). Most had their patients on nucleoside/nucleotide analogue but follow-up visits after 1 year were problematic.

CONCLUSION

The majority of hepatologists had good intentions regarding the evaluation of their patients, but only a small percentage of patients are properly investigated.

Noninvasive assessment of hepatic fibrosis in patients with chronic hepatitis B viral infection using magnetic resonance elastography

Objective

To evaluate the diagnostic performance of magnetic resonance elastography (MRE) for staging hepatic fibrosis in patients with chronic hepatitis B virus (HBV) infection.

Materials and Methods

Patients with chronic HBV infection who were suspected of having focal or diffuse liver diseases (n = 195) and living donor candidates (n = 166) underwent MRE as part of the routine liver MRI examination. We measured liver stiffness (LS) values on quantitative shear stiffness maps. The technical success rate of MRE was then determined. Liver cell necroinflammatory activity and fibrosis were assessed using histopathologic examinations as the reference. Areas under the receiver operating characteristic curve (Az) were calculated in order to predict the liver fibrosis stage.

Results

The technical success rate of MRE was 92.5% (334/361). The causes of technical failure were poor wave propagation (n = 12), severe respiratory motion (n = 3), or the presence of iron deposits in the liver (n = 12). The mean LS values, as measured by MRE, increased significantly along with an increase in the fibrosis stage (r = 0.901, p < 0.001); however, the mean LS values did not increase significantly along with the degree of necroinflammatory activity. The cutoff values of LS for ≥ F1, ≥ F2, ≥ F3, and F4 were 2.45 kPa, 2.69 kPa, 3.0 kPa, and 3.94 kPa, respectively, and with Az values of 0.987-0.988.

Conclusion

MRE has a high technical success rate and excellent diagnostic accuracy for staging hepatic fibrosis in patients with chronic HBV infection.

Ultrasonographic scoring system score versus liver stiffness measurement in prediction of cirrhosis

BACKGROUND/AIMS

We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis.

METHODS

Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated.

RESULTS

The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4.

CONCLUSIONS

The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.

Ultrasonographic scoring system score versus liver stiffness measurement in prediction of cirrhosis

Background/Aims

We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis.

Methods

Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated.

Results

The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4.

Conclusions

The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.

Significant fibrosis is not rare in Chinese chronic hepatitis B patients with persistent normal ALT

Background

Limited studies have been done on chronic hepatitis B (CHB) patients defined according to the latest Asian-Pacific Association for the Study of the Liver guideline with liver histology by a large sample size.

Methods

We retrospectively evaluated liver histological characteristics on a cohort of consecutive treatment-naive CHB patients with persistent normal alanine aminotransferase (PNALT) or elevated ALT from May 2005 to October 2011. Histological assessment was based on the Metavir scoring system, significant abnormality was defined as necroinflammation grade ≥A2 and/or fibrosis stage ≥F2.

Results

A total of 675 CHB patients were recruited, including 516 HBeAg-positive and 159 HBeAg-negative patients. In HBeAg-positive patients, significant fibrosis was found 49.4% (42/85) in PNALT, 69.8% (88/126) in ALT 1-2×upper limit normal (ULN) and 81.6% (249/305) in ALT>2×ULN group, respectively. In HBeAg-negative patients, significant fibrosis was found 30.9% (17/55) in PNALT, 73.3% (33/45) in ALT 1-2×ULN and 94.9% (56/59) in ALT>2×ULN group, respectively. HBeAg-positive patients with PNALT over 30 years old had a higher frequency of significant fibrosis than those under 30 years old (87.5% vs. 45.5%, P = 0.058). Multivariate logistic regression analysis indicated increasing age (P = 0.012), higher aspartate aminotransferase (AST) (P < 0.001) and lower HBV DNA (P < 0.001) were associated with significant necroinflammation, while higher AST (P < 0.001), lower albumin (P = 0.027) and HBV DNA (P = 0.004) were associated with significant fibrosis in HBeAg-positive patients with elevated ALT. Higher AST was associated with significant necroinflammation in HBeAg-negative patients with elevated ALT (P = 0.009).

Conclusions

Significant fibrosis is not rare in Chinese CHB patients with PNALT, especially HBeAg-positive patients over 30 years old.

High hepatitis B surface antigen levels predict insignificant fibrosis in hepatitis B e antigen positive chronic hepatitis B

Introduction

There is no data on the relationship between hepatitis B surface antigen (HBsAg) levels and liver fibrosis in hepatitis B e antigen (HBeAg)-positive patients with chronic hepatitis B (CHB).

Methods

Serum HBsAg and HBV DNA levels in HBeAg-positive CHB patients with liver biopsies were analyzed. The upper limit of normal (ULN) of alanine aminotransferase (ALT) was 30 and 19 U/L for men and women respectively. Histologic assessment was based on Ishak fibrosis staging for fibrosis and Knodell histologic activity index (HAI) for necroinflammation.

Results

140 patients (65% male, median age 32.7 years) were recruited. 56 (40%) had ALT ≤2×ULN. 72 (51.4%) and 42 (30%) had fibrosis score ≤1 and necroinflammation grading ≤4 respectively. Patients with fibrosis score ≤1, when compared to patients with fibrosis score >1, had significantly higher median HBsAg levels (50,320 and 7,820 IU/mL respectively, p<0.001). Among patients with ALT ≤2×ULN, serum HBsAg levels achieved an area under receiver operating characteristic curve of 0.869 in predicting fibrosis score ≤1. HBsAg levels did not accurately predict necroinflammation score. HBsAg ≥25,000 IU/mL was independently associated with fibrosis score ≤1 (p = 0.025, odds ratio 9.042).Using this cut-off HBsAg level in patients with ALT ≤2×ULN, positive and negative predictive values for predicting fibrosis score ≤1 were 92.7% and 60.0% respectively. HBV DNA levels had no association with liver histology.

Conclusion

Among HBeAg-positive patients with ALT ≤2×ULN, high serum HBsAg levels can accurately predict fibrosis score ≤1, and could potentially influence decisions concerning treatment commencement and reduce the need for liver biopsy.

Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2012 update

Large volume of new data on the natural history and treatment of chronic hepatitis B virus (HBV) infection have become available since 2008. These include further studies in asymptomatic subjects with chronic HBV infection and community-based cohorts, the role of HBV genotype/naturally occurring HBV mutations, the application of non-invasive assessment of hepatic fibrosis and quantitation of HBV surface antigen and new drug or new strategies towards more effective therapy. To update HBV management guidelines, relevant new data were reviewed and assessed by experts from the region, and the significance of the reported findings was discussed and debated. The earlier "Asian-Pacific consensus statement on the management of chronic hepatitis B" was revised accordingly. The key terms used in the statement were also defined. The new guidelines include general management, indications for fibrosis assessment, time to start or stop drug therapy, choice of drug to initiate therapy, when and how to monitor the patients during and after stopping drug therapy. Recommendations on the therapy of patients in special circumstances, including women in childbearing age, patients with antiviral drug resistance, concurrent viral infection, hepatic decompensation, patients receiving immune suppression or chemotherapy and patients in the setting of liver transplantation and hepatocellular carcinoma, are also included.