Non-invasive tests in prediction of liver fibrosis in chronic hepatitis B and comparison with post-antiviral treatment results

Serum alanine aminotransferase to hemoglobin ratio and radiological features predict the prognosis of postoperative adjuvant TACE in patients with hepatocellular carcinoma

Objective

To explore the prognostic value of radiological features and serum indicators in patients treated with postoperative adjuvant transarterial chemoembolization (PA-TACE) and develop a prognostic model to predict the overall survival (OS) of patients with hepatocellular carcinoma (HCC) treated with PA-TACE.

Method

We enrolled 112 patients (75 in the training cohort and 37 in the validation cohort) with HCC treated with PA-TACE after surgical resection at the Affiliated Hospital of Nantong University between January 2012 and June 2015. The independent OS predictors were determined using univariate and multivariate regression analyses. Decision curve analyses and time-dependent receiver operating characteristic curve analysis was used to verify the prognostic performance of the different models; the best model was selected to establish a multi-dimensional nomogram for predicting the OS of HCC patients treated with PA-TACE.

Result

Multivariate regression analyses indicated that rim-like arterial phase enhancement (IRE), peritumor capsule (PTC), and alanine aminotransferase to hemoglobin ratio (AHR) were independent predictors of OS after PA-TACE. The combination of AHR had the best clinical net benefit and we constructed a prognostic nomogram based on IRE, PTC, and AHR. The calibration curve showed good fit between the predicted nomogram’s curve and the observed curve.

Conclusion

Our preliminary study confirmed the prognostic value of AHR, PTC, and IRE and established a nomogram that can predict the OS after PA-TACE treatment in patients with HCC.

LOXL-2 and TNC-C are markers of liver fibrogenesis in HCV/HIV-, HIV- and HCV-infected patients

Background: Lysil oxidase like enzyme-2 (LOXL-2) and TNC-C play important roles in organ fibrosis. We assessed circulating LOXL-2 and TNC-C levels and their relationship to fibrosis severity in HIV- and/or HCV-infected individuals. Methods: Healthy controls (n = 22), HIV mono- (n = 15), HCV mono- (n = 52) and HCV/HIV-co-infected (n = 92) subjects were included. Results: LOXL-2 and TNC-C levels were significantly higher in HCV mono- and HCV/HIV-co-infected individuals with F0 compared to healthy controls. In addition, in HCV/HIV-co-infected individuals, LOXL-2 levels were higher in intermediate fibrosis compared to no/mild fibrosis. Conclusion: In HCV/HIV-co-infected study participants, both LOXL-2 and TNC-C were significantly higher in intermediate fibrosis compared to no/mild fibrosis, but did not further increase with advanced fibrosis. Furthermore, both markers were elevated among HCV/HIV-positive individuals with mild/no fibrosis.

Development and validation of a non-invasive model for diagnosing HBV-related liver cirrhosis

BACKGROUND

Liver cirrhosis is closely related to the abnormal liver function and occurrence of liver cancer. Accurate non-invasive assessment of liver cirrhosis is of great significance for preventing disease progression and treatment decision-making. We aim to develop and validate a non-invasive diagnostic model for liver cirrhosis in patients with chronic hepatitis B (CHB).

METHODS

From July 2015 to April 2017, seven-hundred fifty-four patients with primary HBV-related liver cancer who underwent hepatectomy were reprospectively recruited. All patients were examined with 2D-SWE and serologic testing preoperatively, which were utilized for measurement of liver stiffness and serum fibrosis models. The stage of liver fibrosis was evaluated using a resected liver specimen. Least absolute shrinkage and selection operator (Lasso) regression was used for feature selection and binary logistic regression analysis was chosen to build a diagnostic model, which was presented as a nomogram and evaluated for calibration, discrimination and clinical usefulness. The performance of noninvasive model was then prospectively validated in an independent cohort (361 patients) by the ROC curve analysis.

RESULTS

The diagnostic model, which consists of 5 selected clinical characteristics (PIII-NP, IV-C, Hyaluronan, Platelet and Liver stiffness), showed the strongest correlation with liver fibrosis stage (ρ = 0.702, P < 0.05). Compared with APRI, FIB-4, King's Score, and Forns Index, the model presented the optimal discrimination and the best predictive performance with the highest AUC in the training cohort (0.866, 95%CI 0.840-0.892, P < 0.05) and validation cohorts (0.852, 95%CI 0.813-0.890, P < 0.05). Decision curve analysis demonstrated that nomogram based on the model was extremely useful for diagnosing cirrhosis in patients with chronic hepatitis B.

CONCLUSION

This study proposes a non-invasive diagnostic model that incorporates the clinical predictors which can be conveniently used in the individualized diagnosis of HBV-related liver cirrhosis.

Comparison of two-dimensional shear wave elastography, magnetic resonance elastography, and three serum markers for diagnosing fibrosis in patients with chronic hepatitis B: a meta-analysis

BACKGROUND

Two-dimensional shear wave elastography (2D-SWE), magnetic resonance elastography (MRE), aspartate transaminase-to-platelet ratio index (APRI), fibrosis index based on 4 factors (FIB-4), and King's score have been proposed for diagnosing fibrosis.

METHODS

Literature databases were searched until October 1st, 2020. The summary area under the receiver operating characteristic curve (AUROC), the summary diagnostic odds ratios, and the summary sensitivities and specificities were used to assess the performance of these noninvasive methods for staging fibrosis.

RESULTS

Our final data contained 72 studies. The prevalence of significant fibrosis, advanced fibrosis, and cirrhosis was 58.3%, 36.2%, and 20.5%, respectively, in chronic hepatitis B (CHB). For 2D-SWE and MRE, the summary AUROCs were 0.89 and 0.97, 0.95 and 0.97, and 0.94 and 0.97 for significant fibrosis, advanced fibrosis, and cirrhosis, respectively. The summary AUROCs using APRI and FIB-4 for detecting significant fibrosis, advanced fibrosis, and cirrhosis were 0.76 and 0.75, 0.74 and 0.77, and 0.77 and 0.82, respectively. The summary AUROCs of King's score for detecting significant fibrosis and cirrhosis were 0.77 and 0.83, respectively.

CONCLUSION

MRE and 2D-SWE may show the best diagnostic accuracy for predicting fibrosis in CHB. Among the three serum markers, King's score may be more useful for diagnosing fibrosis.

Identification and external validation of the optimal FIB-4 and APRI thresholds for ruling in chronic hepatitis B related liver fibrosis in tertiary care settings

BACKGROUND

With the initially defined thresholds, the most widely used serum biomarkers for staging liver fibrosis (ie, APRI and FIB-4 scores) proved to be ineffective among patients with chronic hepatitis B virus infection (CHB). Whether optimizing the FIB-4 and APRI thresholds could improve their diagnostic accuracy requires further research.

METHODS

Using data of treat-naïve CHB patients from three tertiary hospitals, we explored the optimal FIB-4 and APRI thresholds to rule in liver fibrosis accurately. Subsequently, we validated the applicability of the newly defined thresholds to the CHB patients from another two tertiary hospitals.

RESULTS

The fibrosis stages between discovery cohort (n = 433) and the external validation cohort (n = 568) were statistically different (P < .001). When ruling in significant fibrosis and advanced fibrosis by the newly defined FIB-4 thresholds (2.25 and 3.00, respectively), 24.0% and 14.3% of patients, respectively, could be classified with excellent accuracy (PPVs of 91.3% and 80.6%, respectively; misdiagnosis rates of 6.0% and 5.4%, respectively), supported by the internal and external validation tests. Regrettably, the more accurate and robust thresholds of APRI score for ruling in significant fibrosis and advanced fibrosis could not be found. Besides, the FIB-4 and APRI scores should not be recommended for ruling in cirrhosis because of poor clinical diagnostic performance.

CONCLUSION

The newly defined FIB-4 thresholds for ruling in significant fibrosis and advanced fibrosis showed superior and reproducible clinical diagnostic accuracy. The well-validated threshold (≥2.25) of FIB-4 score could aid in antiviral treatment decisions for treat-naïve adult CHB patients by accurately ruling in significant fibrosis in tertiary care settings.

Performance of common imaging techniques vs serum biomarkers in assessing fibrosis in patients with chronic hepatitis B: A systematic review and meta-analysis

BACKGROUND

Noninvasive biomarkers have been developed to predict hepatitis B virus (HBV) related fibrosis owing to the significant limitations of liver biopsy. Both serum biomarkers and imaging techniques have shown promising results and may improve the evaluation of liver fibrosis. However, most of the previous studies focused on the diagnostic effects of various imaging techniques on fibrosis in all chronic liver diseases.

AIM

To compare the performance of common imaging methods and serum biomarkers for prediction of significant fibrosis caused only by HBV infection.

METHODS

A systematic review was conducted on the records available in PubMed, EMBASE, and the Cochrane Library electronic databases until December 2018. We systematically assessed the effectiveness of two serum biomarkers and three imagine techniques in predicting significant fibrosis solely caused by HBV infection. The serum biomarkers included aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4). The three imaging techniques included acoustic radiation force impulse (ARFI), FibroScan, and magnetic resonance elastography (MRE). Three parameters, the area under the summary receiver operating characteristic curve (AUSROC), the summary diagnostic odds ratio, and the summary sensitivity and specificity, were used to examine the accuracy of all tests for liver fibrosis.

RESULTS

Out of 2831 articles evaluated for eligibility, 204 satisfied the predetermined inclusion criteria for this current meta-analysis. Eventually, our final data contained 81 studies. The AUSROCs of serum biomarkers of APRI and FIB-4 were both 0.75. For imaging techniques (ARFI, FibroScan, and MRE), the areas were 0.89, 0.83, and 0.97, respectively. The heterogeneities of ARFI and FibroScan were statistically significant (I² > 50%). The publication bias was not observed in any of the serum biomarkers or imaging methods.

CONCLUSION

These five methods have attained an acceptable level of diagnostic accuracy. Imaging techniques, MRE in particular, demonstrate significant advantages in accurately predicting HBV-related significant fibrosis, while serum biomarkers are admissible methods.

Longitudinal effects of Nucleos(t)ide analogue therapy in chronic hepatitis B patients and the utility of non-invasive fibrosis markers during treatment: A single-center experience for up to 17 years

BACKGROUND

Fibrosis regression has been associated with nucleoside analogue (NA) treatment in chronic hepatitis B (CHB) patients. Although non-invasive fibrosis markers have been evaluated in CHB, their utility for monitoring on-treatment histologic regression has not been evaluated.

AIMS

To characterize improvements in disease severity and the utility of non-invasive biomarkers in CHB NA treated patients.

METHODS

Histology, labs, AST-to-platelet ratio index, and Fibrosis-4 (Fib-4) from treatment-naïve CHB patients were evaluated at baseline and longitudinally. Relative change from baseline to various time points during treatment were evaluated. Correlative analysis of APRI and Fib-4 with histology was performed longitudinally.

RESULTS

80 CHB patients (84% male, median age 45 (IQR 32, 54)) with histology up to 17 years (median 6(IQR 3.9, 8.0)) years were studied. Median baseline Ishak fibrosis was 3 (IQR 2, 4), histologic activity index (HAI) inflammation was 9 (IQR 7, 11), and AUROC of fibrosis markers for detecting cirrhosis (Ishak ≥ 5) was >0.64. HAI improved at a rate of 54% during year 1 and 37% in year 2, both greater than in the remaining follow-up periods. Within the first year, fibrosis improved by 35%, greater than all other time periods. Non-invasive biomarkers began to correlate with histology beyond 4 years (APRI: 4-6 years: r = 0.33, p = 0.03; ≥6 years: r = 0.41, p = 0.009; Fib-4: ≥6 years: r = 0.35, p = 0.03).

CONCLUSION

Early dynamic changes in histology occur in CHB patients on NA followed by linear improvements. Non-invasive fibrosis biomarkers do not capture these dynamic changes and may demonstrate clinical utility beyond 4 years of treatment.

Validation and comparison of seventeen noninvasive models for evaluating liver fibrosis in Chinese hepatitis B patients

BACKGROUND & AIMS

To avoid liver biopsy, many noninvasive models comprised of serum markers for liver fibrosis assessment have been developed. Given that most of them were developed in hepatitis C cohorts and few of them have been validated in Chinese hepatitis B patients, we aim to conduct this validation and compare their diagnostic accuracies in such a population.

METHODS

A total of 937 HBV-infected patients who underwent liver biopsy were included in this single-centre retrospective study. The diagnostic accuracies of the 17 noninvasive models were assessed by areas under the receiver-operating characteristic curves (AUROCs), using histologically evaluated fibrotic stages of the biopsy specimens as standards. To compare efficiencies of the models, a grading system based on AUROC levels was developed.

RESULTS

For discriminating significant fibrosis in all patients, the best three noninvasive models were King's score (AUROC = 0.756), Virahep-C model (AUROC = 0.756) and GPR (AUROC = 0.744); and for diagnosing cirrhosis, Lok index (AUROC = 0.832), FI (AUROC = 0.820) and FIB-4 (AUROC = 0.818) got the first three places. AUROCs in HBeAg-positive group were generally higher than those in HBeAg-negative group. In addition, based on the grading system, Virahep-C and GPR outstood others in evaluating liver fibrosis in all patients.

CONCLUSIONS

In Chinese HBV-infected patients, Virahep-C models and GPR had high accuracies in diagnosing liver fibrosis and cirrhosis, while the most discussed models like APRI and FIB-4 did not outstand. Assessment should take into account the HBeAg sero-status, since these noninvasive models were more appropriate for HBeAg-positive patients than HBeAg-negative ones.

Impact of HBV replication in peripheral blood mononuclear cell on HBV intrauterine transmission

This study determined the effect of hepatitis B virus (HBV) replication in peripheral blood mononuclear cell (PBMC) from HBsAg-positive mothers on HBV intrauterine transmission. A total of 150 HBsAg-positive mothers and their neonates were recruited in this study. Within 24 h after birth, HBV serological markers, serum HBV DNA, PBMC HBV relaxed circular DNA (rcDNA), and covalently closed circular DNA (cccDNA) were measured in the HBsAg-positive mothers and their neonates before passive-active immune prophylaxis. The relationship between HBV replication in PBMC and HBV intrauterine transmission was examined through Chisquare test and logistic regression. The rate of HBV intrauterine transmission was 8.00% (12/150) in the 150 neonates born to HBsAg-positive mothers. The positivities of PBMC HBV rcDNA and cccDNA in the HBsAg-positive mothers were 36.67% (55/150) and 10% (15/150), respectively. Maternal PBMC HBV cccDNA was a risk factor of HBV intrauterine transmission (OR = 6.003, 95% CI: 1.249-28.855). Maternal serum HBeAg was a risk factor of PBMC HBV rcDNA (OR = 3.896, 95% CI: 1.929-7.876) and PBMC HBV cccDNA (OR = 3.74, 95% CI: 1.186-11.793) in the HBsAg-positive mothers. Administration of hepatitis B immune globulin was a protective factor of PBMC HBV cccDNA (OR = 0.312, 95%CI: 0.102-0.954) during pregnancy. The positivity of PBMC HBV rcDNA was related to that of cccDNA in the HBsAg-positive mothers (χ ²= 5.087, P = 0.024). This study suggests that PBMC is a reservoir of HBV and an extrahepatic site for virus replication and plays a critical role in HBV intrauterine transmission.

Diagnostic value of FIB-4 for liver fibrosis in patients with hepatitis B: a meta-analysis of diagnostic test

This study is aimed at evaluating the diagnostic value of FIB-4 for liver fibrosis in patients with hepatitis B through a meta-analysis of diagnostic test. We conducted a comprehensive search in the Pubmed, Embase, Web of Science, and Chinese National Knowledge Infrastructure before October 31, 2016. Stata 14.0 software was used for calculation and statistical analyses. We used the sensitivity, specificity, positive and negative likelihood ratio (PLR, NLR), diagnostic odds ratio (DOR) and 95% confidence intervals (CIs) to evaluate the diagnostic value of FIB-4 for liver fibrosis in patients with hepatitis B. Twenty-six studies were included in the final analyses, with a total of 8274 individuals. The pooled parameters are calculated from all studies: sensitivity of 0.69 (95%CI:0.63-0.75), specificity of 0.81 (95%CI: 0.73-0.87), PLR of 3.63 (95%CI:2.66-4.94), NLR of 0.38 (95%CI:0.32-0.44), DOR of 9.57 (95%CI: 6.67-13.74), and area under the curve (AUC) of 0.80 (95%CI: 0.76-0.83). We also conducted subgroup based on the range of cut-off values. Results from subgroup analysis showed that cut-off was the source of heterogeneity in the present study. The sensitivity and specificity of cut-off>2 were 0.69 and 0.95 with the AUC of 0.90 (95%CI: 0.87-0.92). The overall diagnostic value of FIB-4 is not very high for liver fibrosis in patients with hepatitis B. However, the diagnostic value is affected by the cut-off value. FIB-4 has relatively high diagnostic value for detecting liver fibrosis in patients with hepatitis B when the diagnostic threshold value is more than 2.0.

The ability of Hepascore to predict liver fibrosis in chronic liver disease: a meta-analysis

BACKGROUND & AIMS

Hepascore is a serum model that was developed to assess the severity of liver fibrosis. It has been well validated in common causes of chronic liver disease. This study performed a meta-analysis to evaluate the pooled diagnostic performance of Hepascore and to compare it for different aetiologies of chronic liver disease.

METHODS

Two reviewers searched electronic databases from October 2005 to September 2015 for studies that evaluated the diagnostic performance of Hepascore for liver fibrosis in chronic liver disease.

RESULTS

21 studies were included. The AUROC was adjusted according to the distribution of fibrosis stages. The mean adjusted AUROC was 0.83 (95% CI, 0.81-0.85) for significant fibrosis, 0.89 (95% CI, 0.85-0.92) for advance fibrosis and 0.93 (95% CI, 0.91-0.95) for cirrhosis. A cut point of 0.50-0.55 achieved a summary sensitivity of 70% and a summary specificity of 79% to predict significant fibrosis. A cut point of 0.50-0.61 had a summary sensitivity of 81% and a summary specificity of 74% to predict advanced fibrosis. A cut point of 0.80-0.84 had a summary sensitivity of 72% and a summary specificity of 0.88% to predict cirrhosis. The accuracy of Hepascore was similar among all disease aetiologies for the prediction of cirrhosis. However, Hepascore had better diagnostic ability for significant and advanced fibrosis in chronic hepatitis C, chronic hepatitis B and alcoholic liver disease than for non-alcoholic fatty liver disease and HIV co-infected viral hepatitis.

CONCLUSIONS

Hepascore is a clinically useful measure of liver fibrosis in patients with common causes of chronic liver disease.

Effect of Entecavir and Tenofovir Treatment on Noninvasive Fibrosis Scores: Which One Is Better?

Liver biopsy is the best method for detecting fibrosis grade of the liver in chronic hepatitis B. However, the invasiveness of liver biopsy complicates its routine use in follow-up of treatment. We planned to determine the usage of fibrosis predicting noninvasive scores in the follow-up of the treatment of patients with chronic hepatitis B treated with entecavir or tenofovir. Two hundred twenty-eight patients with hepatitis B with liver biopsy were included in the study. Fibrosis grade was determined by Ishak score. The laboratory data at months 0, 12, and 24 during treatment were collected and noninvasive fibrosis scores (aspartate aminotransferase to alanine aminotransferase ratio [AAR], aspartate aminotransferase to platelet ratio index [APRI], fibrosis index based on the 4 factors [FIB-4] and red cell distribution width to platelet ratio [RPR]) were calculated. Statistically significant increase in all scores and decrease in platelet count were observed as the fibrosis level increased. For differentiation of patients with fibrosis ≥grade 2, the highest sensitivity and specificity rates were shown by APRI score (sensitivity 67%, specificity 69%, and cutoff ≥0.5). FIB-4 was the most successful score for differentiation of patients with fibrosis ≥grade 3 (sensitivity 83%, specificity 74%, and cutoff ≥1.45). A significant decrease in all noninvasive fibrosis scores was observed at months 12 and 24 during treatment with both entecavir and tenofovir (P < 0.001). Among these, only the improvement in APRI score was found better in entecavir group with statistical significance (P < 0.05). APRI score was effective in demonstrating early-stage fibrosis. FIB-4, RPR, and platelet count were better in demonstrating advanced fibrosis. Although noninvasive scores cannot replace liver biopsy for diagnosis, they can be used for monitoring the response to treatment.

The Role of M30 in Predicting the Severity of Liver Fibrosis and Inflammation in Chronic Hepatitis B Patients

BACKGROUND

Liver biopsy is an invasive procedure that is currently still necessary for predicting underlying hepatic injury related to chronic viral hepatitis B (CVHB). To date, none of the studied non-invasive methods have been able to replace liver biopsy. An apoptotic serum marker, M30, which has been reported to indicate ongoing liver fibrosis, has been popular in recent years.

OBJECTIVES

We aimed to investigate the possible role of M30 in predicting CVHB-associated hepatic injury and its severity.

METHODS

Forty-eight patients undergoing liver biopsy for evaluation of the severity of CVHB-related liver injury and 40 healthy controls were included in this cross-sectional study. M30 levels were determined for all CVHB patients and controls, and other laboratory parameters and demographic features were obtained from our hospital's database.

RESULTS

The mean ages of patients and controls were 39.7 and 45.7 years, respectively, and 35% of the controls and 52% of the patients were male. In contrast to lower platelet counts, transaminase and M30 levels were both higher in the patient group than in the controls. Among the investigated parameters, only transaminase increased as the fibrosis stage changed from mild to moderate; however, none of the laboratory parameters, including M30, differed as the histological activity index (HAI) score increased.

CONCLUSIONS

M30 levels were higher in CVHB patients compared to healthy controls. However, M30 levels were similar in the mild and moderate stages of fibrosis, so they did not indicate the severity of underlying fibrotic or inflammatory processes in CVHB patients.

Noninvasive models for assessment of liver fibrosis in patients with chronic hepatitis B virus infection

There are approximately 240 million patients with chronic hepatitis B virus (HBV) infection worldwide. Up to 40% of HBV-infected patients can progress to liver cirrhosis, hepatocellular carcinoma or chronic end-stage liver disease during their lifetime. This, in turn, is responsible for around 650000 deaths annually worldwide. Repeated hepatitis flares may increase the progression of liver fibrosis, making the accurate diagnosis of the stage of liver fibrosis critical in order to make antiviral therapeutic decisions for HBV-infected patients. Liver biopsy remains the “gold standard” for diagnosing liver fibrosis. However, this technique has recently been challenged by the development of several novel noninvasive tests to evaluate liver fibrosis, including serum markers, combined models and imaging techniques. In addition, the cost and accessibility of imaging techniques have been suggested as additional limitations for invasive assessment of liver fibrosis in developing countries. Therefore, a noninvasive assessment model has been suggested to evaluate liver fibrosis, specifically in HBV-infected patients, owing to its high applicability, inter-laboratory reproducibility, wide availability for repeated assays and reasonable cost. The current review aims to present the status of knowledge in this new and exciting field, and to highlight the key points in HBV-infected patients for clinicians.

The Diagnostic Accuracy and Clinical Utility of Three Noninvasive Models for Predicting Liver Fibrosis in Patients with HBV Infection

Aim

To evaluate the diagnostic accuracy and clinical utility of the fibrosis index based on the four factors (FIB-4), aspartate aminotransferase -to-platelet ratio index (APRI), and aspartate aminotransferase–alanine aminotransferase ratio index (AAR) for predicting liver fibrosis in patients with HBV infection.

Methods

From January 2006 to December 2010,a total of 1543 consecutive chronic hepatitis B(CHB) patients who underwent liver biopsies were enrolled. FIB-4,APRI, and AAR were calculated.The areas under the receiver-operating characteristic curves (AUROCs) were calculated to assess the diagnostic accuracy of these models.The AUROCs of these models were compared by DeLong’s test.For further comparisons in different studies,the AUROCs were adjusted to conduct Adjusted AUROCs(ADjAUROCs) according to the prevalence of fibrosis stages using the difference between advanced and nonadvanced fibrosis (DANA).

Results

For prediction of significant fibrosis,severe fibrosis,and cirrhosis,the AUROCs of FIB-4 were 0.646(ADjAUROC 0.717),0.670(ADjAUROC 0.741), and 0.715(ADjAUROC 0.786) respectively;whereas it were 0.656(ADjAUROC 0.727),0.653(ADjAUROC 0.724) and 0.639(ADjAUROC 0.710) for APRI, 0.498(ADjAUROC 0.569),0.548(ADjAUROC 0.619) and 0.573(ADjAUROC 0.644) for AAR. The further comparisons demonstrated that there were no significant differences of AUROCs between FIB-4 and APRI in predicting significant and severe fibrosis(P > 0.05),while FIB-4 was superior to APRI in predicting cirrhosis(P < 0.001). Further subgroup analysis demonstrated that the diagnostic accuracy of FIB-4 and APRI in patients with normal alanine aminotransferase(ALT) were higher than that in patients with elevated ALT.

Conclusions

The results demonstrated that FIB-4 and APRI are useful for diagnosis of fibrosis. FIB-4 and APRI have similar diagnostic accuracy in predicting significant and severe fibrosis,while FIB-4 is superior to APRI in predicting cirrhosis. The clinical utility of FIB-4 and APRI for fibrosis need further external validation in a large population before it was used for prediction of fibrosis in patients with HBV infection.

Hyaluronic acid algorithm-based models for assessment of liver fibrosis: translation from basic science to clinical application

BACKGROUND

The estimation of liver fibrosis is usually dependent on liver biopsy evaluation. Because of its disadvantages and side effects, researchers try to find non-invasive methods for the assessment of liver injuries. Hyaluronic acid has been proposed as an index for scoring the severity of fibrosis, alone or in algorithm models. The algorithm model in which hyaluronic acid was used as a major constituent was more reliable and accurate in diagnosis than hyaluronic acid alone. This review described various hyaluronic acid algorithm-based models for assessing liver fibrosis.

DATA SOURCE

A PubMed database search was performed to identify the articles relevant to hyaluronic acid algorithm-based models for estimating liver fibrosis.

RESULT

The use of hyaluronic acid in an algorithm model is an extra and valuable tool for assessing liver fibrosis.

CONCLUSIONS

Although hyaluronic acid algorithm-based models have good diagnostic power in liver fibrosis assessment, they cannot render the need for liver biopsy obsolete and it is better to use them in parallel with liver biopsy. They can be used when frequent liver biopsy is not possible in situations such as highlighting the efficacy of treatment protocol for liver fibrosis.

Comparison of diagnostic accuracy of aspartate aminotransferase to platelet ratio index and fibrosis-4 index for detecting liver fibrosis in adult patients with chronic hepatitis B virus infection: a systemic review and meta-analysis

The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the four factors (Fibrosis 4 index; FIB-4) are the two most widely studied noninvasive tools for assessing liver fibrosis. Our aims were to systematically review the performance of APRI and FIB-4 in hepatitis B virus (HBV) infection in adult patients and compare their advantages and disadvantages. We examined the diagnostic accuracy of APRI and FIB-4 for significant fibrosis, advanced fibrosis, and cirrhosis based on their sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUROC). Heterogeneity was explored using metaregression. Our systemic review and meta-analysis included 16 articles of APRI only, 21 articles of APRI and FIB-4 and two articles of FIB-4 for detecting different levels of liver fibrosis. With an APRI threshold of 0.5, 1.0, and 1.5, the sensitivity and specificity values were 70.0% and 60.0%, 50.0% and 83.0%, and 36.9% and 92.5% for significant fibrosis, advanced fibrosis, and cirrhosis, respectively. With an FIB-4 threshold of 1.45 and 3.25, the sensitivity and specificity values were 65.4% and 73.6% and 16.2% and 95.2% for significant fibrosis. The summary AUROC values using APRI and FIB-4 for the diagnosis of significant fibrosis, advanced fibrosis, and cirrhosis were 0.7407 (95% confidence interval [CI]: 0.7033-0.7781) and 0.7844 (95% CI: 0.7450-0.8238; (Z = 1.59, P = 0.06), 0.7347 (95% CI: 0.6790-0.7904) and 0.8165 (95% CI: 0.7707-0.8623; Z = 2.01, P = 0.02), and 0.7268 (95% CI: 0.6578-0.7958) and 0.8448 (95% CI: 0.7742-0.9154; (Z = 2.34, P = 0.01), respectively.

CONCLUSIONS

Our meta-analysis suggests that APRI and FIB-4 can identify hepatitis B-related fibrosis with a moderate sensitivity and accuracy.

Non-invasive assessment of liver fibrosis in chronic hepatitis B

The goal of this review is to provide a comprehensive picture of the role, clinical applications and future perspectives of the most widely used non-invasive techniques for the evaluation of hepatitis B virus (HBV) infection. During the past decade many non-invasive methods have been developed to reduce the need for liver biopsy in staging fibrosis and to overcome whenever possible its limitations, mainly: invasiveness, costs, low reproducibility, poor acceptance by patients. Elastographic techniques conceived to assess liver stiffness, in particular transient elastography, and the most commonly used biological markers will be assessed against their respective role and limitations in staging hepatic fibrosis. Recent evidence highlights that both liver stiffness and some bio-chemical markers correlate with survival and major clinical end-points such as liver decompensation, development of hepatocellular carcinoma and portal hypertension. Thus the non-invasive techniques here discussed can play a major role in the management of patients with chronic HBV-related hepatitis. Given their prognostic value, transient elastography and some bio-chemical markers can be used to better categorize patients with advanced fibrosis and cirrhosis and assign them to different classes of risk for clinically relevant outcomes. Very recent data indicates that the combined measurements of liver and spleen stiffness enable the reliable prediction of portal hypertension and esophageal varices development.

The diagnostic value of the FIB-4 index for staging hepatitis B-related fibrosis: a meta-analysis

Background

Liver fibrosis stage is an important factor in determining prognosis and need for treatment in patients infected with hepatitis B virus (HBV). Liver biopsies are typically used to assess liver fibrosis; however, noninvasive alternatives such as the FIB-4 index have also been developed.

Aims

To quantify the accuracy of the FIB-4 index in the diagnosis of HBV related fibrosis and cirrhosis.

Methods

A meta-analysis of studies comparing the diagnostic accuracy of the FIB-4 index vs. liver biopsy in HBV-infected patients was performed using studies retrieved from the following databases: PubMed, Ovid, EMBASE, the Cochrane Library, the Chinese National Knowledge Infrastructure and the Chinese Biology Medicine disc. A hierarchical summary receiver operating curves model and bivariate model were used to produce summary receiver operating characteristic curves and pooled estimates of sensitivity and specificity. The heterogeneity was explored with meta-regression analysis. Publication bias was detected using Egger’s test and the trim and fill method.

Results

12 studies (N = 1,908) and 10 studies (N = 2,105) were included in the meta-analysis for significant fibrosis and cirrhosis, respectively. For significant fibrosis, the area under the hierarchical summary receiver operating curve (AUHSROC) was 0.78 (95% CI = 0.74–0.81). The recommended cutoff value was between 1.45 and 1.62, and the AUHSROC, summary sensitivity and specificity were 0.78 (95% CI = 0.74–0.81), 0.65 (95% CI = 0.56–0.73) and 0.77 (95% CI = 0.7–0.83), respectively. For cirrhosis, the AUHSROC was 0.89 (95% CI = 0.85–0.91). The recommended cutoff value was between 2.9 and 3.6, and the AUHSROC, summary sensitivity and specificity were 0.96 (95% CI = 0.92–1.00), 0.42 (95% CI = 0.36–0.48) and 0.96 (95% CI = 0.95–0.97), respectively. No publication bias was detected.

Conclusions

The FIB-4 index is valuable for detecting significant fibrosis and cirrhosis in HBV-infected patients, but has suboptimal accuracy in excluding fibrosis and cirrhosis.

The effectiveness of noninvasive biomarkers to predict hepatitis B-related significant fibrosis and cirrhosis: a systematic review and meta-analysis of diagnostic test accuracy

Noninvasive biomarkers have been developed to predict hepatitis B virus (HBV)-related fibrosis owing to the significant limitations of liver biopsy. Those biomarkers were initially derived from evaluation of hepatitis C virus (HCV)-related fibrosis, and their accuracy among HBV-infected patients was under constant debate. A systematic review was conducted on records in PubMed, EMBASE and the Cochrane Library electronic databases, up until April 1st, 2013, in order to systematically assess the effectiveness and accuracy of these biomarkers for predicting HBV-related fibrosis. The questionnaire for quality assessment of diagnostic accuracy studies (QUADAS) was used. Out of 115 articles evaluated for eligibility, 79 studies satisfied the pre-determined inclusion criteria for meta-analysis. Eventually, our final data set for the meta-analysis contained 30 studies. The areas under the SROC curve for APRI, FIB-4, and FibroTest of significant fibrosis were 0.77, 0.75, and 0.84, respectively. For cirrhosis, the areas under the SROC curve for APRI, FIB-4 and FibroTest were 0.75, 0.87, and 0.90, respectively. The heterogeneity of FIB-4 and FibroTest were not statistically significant. The heterogeneity of APRI for detecting significant fibrosis was affected by median age (P = 0.0211), and for cirrhosis was affected by etiology (P = 0.0159). Based on the analysis we claim that FibroTest has excellent diagnostic accuracy for identification of HBV-related significant fibrosis and cirrhosis. FIB-4 has modest benefits and may be suitable for wider scope implementation.

Pathogenesis of liver cirrhosis

Liver cirrhosis is the final pathological result of various chronic liver diseases, and fibrosis is the precursor of cirrhosis. Many types of cells, cytokines and miRNAs are involved in the initiation and progression of liver fibrosis and cirrhosis. Activation of hepatic stellate cells (HSCs) is a pivotal event in fibrosis. Defenestration and capillarization of liver sinusoidal endothelial cells are major contributing factors to hepatic dysfunction in liver cirrhosis. Activated Kupffer cells destroy hepatocytes and stimulate the activation of HSCs. Repeated cycles of apoptosis and regeneration of hepatocytes contribute to pathogenesis of cirrhosis. At the molecular level, many cytokines are involved in mediation of signaling pathways that regulate activation of HSCs and fibrogenesis. Recently, miRNAs as a post-transcriptional regulator have been found to play a key role in fibrosis and cirrhosis. Robust animal models of liver fibrosis and cirrhosis, as well as the recently identified critical cellular and molecular factors involved in the development of liver fibrosis and cirrhosis will facilitate the development of more effective therapeutic approaches for these conditions.

The utility of thrombopoietin in predicting liver fibrosis in chronic hepatitis B

Many noninvasive serum markers have been studied to determine the liver fibrosis score (LFS). In this study, we aimed to investigate the association between thrombopoietin (TPO) levels and the stage of liver fibrosis in patients with chronic hepatitis B (CHB). Seventy-seven patients (64 active and 13 inactive) with CHB were included in this cross-sectional study. Patients were divided into three groups: In group 1, patients with mild or no fibrosis (F0, F1); in group 2, patients with significant fibrosis (F2-F4); and in group 3, inactive CHB carriers. Digital patient records were used to access pre-treatment laboratory findings including HBV DNA, HBeAg, ALT, AST, total bilirubin, PLT, albumin, INR. Liver biopsies were examined by experienced pathologists in our hospital who were blinded to the data of the patients. Serum TPO levels were measured using commercial ELISA kit. Serum TPO levels were significantly lower in patients with active CHB compared with the inactive carriers (528 vs 687.1 p=0.003). There was no statistically significant difference in TPO levels between the patients with and patients without significant fibrosis (568.9 vs 459.8 p=0.367). Correlation analysis with respect to ALT, AST, TPO, HBV-DNA level, platelet count, histological activity index (HAI) and liver fibrosis score was performed. TPO was only weakly positively correlated with AST, ALT and HBV-DNA levels (r=0.269 p=0.018; r=0.341 p=0.002; r=0.308 p=0.006; respectively) and no correlation in TPO with LFS and HAI was found (r=0.140 p=0.270, r=0.162 p=0.201; respectively). TPO was not associated with significant fibrosis (p=0.270). In conclusion, TPO levels were decreased in active CHB patients compared with inactive carriers but there was no correlation between TPO levels and the stage of fibrosis in active CHB.