Current role of transient elastography in the management of chronic hepatitis B patients

Pediatric Perspectives on Liver Cirrhosis: Unravelling Clinical Patterns and Therapeutic Challenges

Background: Liver cirrhosis presents significant challenges in the pediatric population due to a complex interplay of etiological factors, clinical manifestations, and limited therapeutic options. The leading contributors to cirrhosis among pediatric patients are chronic cholestasis, metabolic disorders present from birth, and long-term hepatitis. Materials and method: Our narrative review aimed to synthesize literature data on the etiology, clinical picture, diagnostic techniques, optimal management of complications, and timely transplantation. Results: The epidemiology of liver cirrhosis in pediatric patients is evolving. The introduction of a universal vaccination and effective long-term viral suppression in viral hepatitis have significantly decreased complications rates. Liver transplantation programs worldwide have also improved the management of cirrhosis complications. Conclusions: Early diagnosis, comprehensive management strategies, and advancements in treatment modalities are critical for improving outcomes. Understanding these differences is crucial in providing age-appropriate care and support for those affected by cirrhosis.

Comparison of superb microvascular imaging and shear wave elastography for assessing liver fibrosis in chronic hepatitis B

Purpose

The present study investigated the effectiveness and applicability of superb microvascular imaging (SMI) in determining the degree of liver fibrosis noninvasively in comparison with shear wave elastography (SWE).

Methods

Ninety-eight consecutive patients with chronic hepatitis B who underwent ultrasound (US)-guided needle biopsy were examined using US combined with SMI and SWE. The predictive performance of the two US techniques in staging liver fibrosis and inflammation was compared with reference to the histological findings obtained from liver biopsy. The intraobserver and interobserver reproducibility of SMI in vascularity scores were evaluated.

Results

SWE values and SMI vascular scores were statistically significantly different among fibrosis stages (χ²(3)=76.3, χ²(3)=81.5, P<0.001). The SWE and SMI models significantly predicted fibrosis stages separately, and SMI scores alone predicted fibrosis stages better than SWE values (50.1% for SWE, 63.5% for SMI, P<0.001). A model with both SMI scores and SWE values together explained 73.2% of variance in fibrosis stages. When other clinical and laboratory predictors were added to the model (81.5%, P<0.001), SWE values and SMI scores remained the main predictors of fibrosis stages. SWE and SMI were also applicable in predicting inflammatory grades, explaining 31% and 34% of variance, respectively, and 37.7% when used together (P<0.001).

Conclusion

Both SWE and SMI had good diagnostic performance in determining the degree of liver fibrosis in chronic hepatitis B patients. The efficacy of SMI was better than that of SWE. SMI can improve diagnostic performance for staging liver fibrosis and shows potential for estimating necroinflammation of the liver.

Diagnostic Performance of 2-D Shear Wave Elastography on the Evaluation of Hepatic Fibrosis with Emphasis on Impact of the Different Region-of-Interest Methods

The purpose of this study was to evaluate the impact of the different region-of-interest (ROI) methods of 2-D shear wave elastography (2-D SWE) on hepatic fibrosis diagnosis. In this retrospective study, 83 patients who underwent 2-D SWE with three ROI methods (a circle ROI, a box ROI and multiple ROIs in an elastogram) and transient elastography (TE) were included. Liver stiffness (LS) was measured five times with each ROI method. These LS values were compared, and their correlation with those obtained from TE was evaluated. The LS values obtained using the three different ROI methods differed statistically (p < 0.001). However, the LS values obtained using each ROI method of 2-D SWE were highly correlated with those obtained using TE (r > 0.7, p < 0.001). All three ROI methods of 2-D SWE had high areas under the receiver operating characteristic curve in diagnosing significant fibrosis and cirrhosis (0.841, 0.820 and 0.840, respectively; 0.962, 0.946 and 0.945, respectively). There were no significant differences in area under the receiver operating characteristic curve among the ROI methods of 2-D SWE. Regardless of the ROI method, 2-D SWE had high performance in diagnosing hepatic fibrosis.

Comparison of Visual Transient Elastography and Shear Wave Elastography in Evaluating Liver Fibrosis in Patients with Chronic Liver Disease

Purpose

This study investigated the effectiveness and feasibility of shear wave elastography ((sound touch elastography) STE and (shear wave elastography) SWE) and visual transient elastography (ViTE) in the noninvasive quantitative diagnosis of liver fibrosis in chronic liver disease (CLD).

Patients and Methods

A total of 106 patients with CLD underwent STE, SWE and ViTE elastography evaluation. The Young’s modulus of the three elastography was valuated and the diagnostic performances of the three techniques for liver fibrosis staging were compared. The area under the receiver operating curve (ROC) for the diagnosis of liver fibrosis was compared. The final diagnosis was based on the histological findings on the liver biopsy.

Results

1) The correlation between ViTE and SWE, ViTE and STE, SWE and STE stiffness values were 0.72, 0.75, 0.75 (P<0.001). 2) The relationship between the results of each elastography technique and the stage of pathological liver fibrosis showed that the more severe the liver fibrosis was, the higher the stiffness value was (all P <0.001). 3) When the three elastography techniques were used to detect the degree of liver fibrosis in different pathological stages, there was no statistical difference in the stabilities of the boxplots. 4) The ROCs of the three elastography techniques (ViTE, SWE and STE) were 0.88, 0.91, 0.92, F0 vs F1-3; 0.84, 0.84, 0.84, F0-1 vs F2-4; 0.80, 0.79, 0.77, F0-2 vs F3-4; 0.80, 0.76, 0.71, F0-3 vs 4; the AUC of ViTE was higher than the AUC of STE in the identification of F4, but there were no statistical differences in the AUCs of other groups.

Conclusion

ViTE has good stability for the liver stiffness measurement (LSM) and a high consistency with shear-wave elastography (SWE and STE). It is an effective tool for evaluating CLD, and its performance is comparable to SWE and STE. The combination of ViTE and STE can improve the specificity of disease diagnosis and do not add extra cost and may improve cost performance.

Nomogram for predicting advanced liver fibrosis and cirrhosis in patients with chronic liver disease

BACKGROUND

We aimed to formulate a novel predictive nomogram to discriminate liver fibrosis stage in patients with chronic liver disease.

METHODS

Nomograms were established based on the results of multivariate analysis. The predictive accuracy of the nomograms was assessed by ROC analysis and calibration. Decision curve analysis (DCA) was used to determine the clinical benefit of the nomograms.

RESULTS

INR, platelets, and N-terminal propeptide type III collagen (PIIINP) were independent predictors for advanced liver fibrosis (≥ S3) and cirrhosis (S4) in patients with chronic liver disease in the training cohort. In the training set, the areas under the ROCs (AUROCs) of nomogram S3S4, APRI, FIB-4, and GPR for stage ≥ S3 were 0.83, 0.71, 0.68, and 0.74, respectively; the AUROCs of nomogram S4, APRI, FIB-4, and GPR for stage S4 were 0.88, 0.74, 0.78, and 0.79, respectively. The calibrations showed optimal agreement between the prediction by the established nomograms and actual observation. In the validation set, the AUROCs of nomogram S3S4, APRI, FIB-4, and GPR for stage ≥ S3 were 0.86, 0.79, 0.78, and 0.81, respectively; the AUROCs of nomogram S4, APRI, FIB-4, and GPR for stage S4 were 0.88, 0.77, 0.81, and 0.83, respectively. Furthermore, the decision curve analysis suggested that the nomograms represent better clinical benefits in both independent cohorts than APRI, FIB-4, and GPR.

CONCLUSION

The constructed nomograms could be a superior tool for discriminating advanced fibrosis and cirrhosis in chronic liver disease.

Chronic hepatitis B virus infection and fibrosis: novel non-invasive approaches for diagnosis and risk stratification

Despite the availability of an effective vaccination, chronic hepatitis B virus (HBV) infection is still a major health concern worldwide. Chronic HBV infection can lead to fibrosis accumulation and overtime to cirrhosis, the principal risk factor for liver failure and hepatocellular carcinoma development. Liver biopsy is still considered the gold standard for fibrosis assessment, even though it is invasive and not exempt of complications. Overtime, several non-invasive methods for the detection of liver fibrosis have been developed and gradually introduced into clinical practice. However, their main limitation is the poor performance for the detection of intermediate stages of fibrosis. Finally, novel serological biomarkers, polygenic risk scores and imaging methods have been proposed in last years as novel promising tools to correctly identify the degree of liver fibrosis and to monitor liver disease progression. In this narrative review, we provide an overview on the novel non-invasive approaches for the evaluation of liver fibrosis and risk stratification of patients with chronic hepatitis B.

Impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with coexisting hepatitis B virus infection

Continuously updated information is helpful for evaluating the safety of long-term systemic drug use in psoriasis patients with concomitant hepatitis B virus (HBV) infection. To investigate the impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with HBV infection. Data of patients during 10-year period were recorded and analyzed. Sixty-six patients (46 males and 20 females) with a mean age of 58.5 ± 13.1 years were recruited. Our study estimated that the 5-year cumulative risks of developing cirrhosis and HCC were 30% and 5%, respectively, in patients receiving systemic treatments for psoriasis. Risks of cirrhosis and HCC were not significantly different between systemic and topical treatment groups. Thirty patients were prescribed systemic treatments (acitretin, methotrexate, ciclosporin, and anti-tumor necrosis factors). Three HBsAg+ patients developed viral reactivation (two patients with methotrexate and one patient with ciclosporin). The effects of systemic treatments for psoriasis on liver outcome in patients with coexisting HBV infection are needed to be determined. HBsAg+ patients are more likely to develop viral reactivation during systemic treatment for psoriasis than HBsAg- patients. Monitoring of liver enzymes and HBV DNA every 3 months is recommended during treatment and for 6 to 12 months after drug discontinuation.

Shear wave elastography may be sensitive and more precise than transient elastography in predicting significant fibrosis

BACKGROUND

Noninvasive measurements including transient elastography (TE) and two-dimensional shear wave elastography (SWE) have been used clinically instead of liver biopsy for regular assessment of liver fibrosis in chronic hepatitis B (CHB) patients.

AIM

To investigate the diagnostic efficiency of SWE compared to TE by assessing independent influencing factors and performance for diagnosing significant fibrosis based on our cohort of treatment-naive CHB patients.

METHODS

Fifty-four treatment-naive CHB patients who underwent liver biopsy to determine whether to initiate antiviral therapy were enrolled. SWE, TE, serum tests and liver biopsy were performed for all participants. The fibrosis-4 and aspartate aminotransferase to platelet ratio index scores were also calculated. Potential independent influencing factors on SWE and TE values were analyzed. Based on liver pathology results, the agreement and correlation were determined, and a comparison of the two methods was performed.

RESULTS

There were 27 cases (50%) of mild fibrosis (F0-F2) and 27 (50%) cases of significant fibrosis (F3-F6); fibrosis was assessed with the Ishak scoring system. Multivariate linear regression analyses revealed that the fibrosis stage was the only factor that affected the SWE values (P < 0.001), whereas the total bilirubin level (P = 0.013) and fibrosis stage (P = 0.037) were independent factors that affected TE values. Orthogonal partial least squares discriminant analysis showed that the number of independent factors (VIP > 1) was higher for TE than SWE. Bland-Altman analysis showed satisfactory agreement between liver stiffness measurements (LSMs) of SWE and TE. Both SWE and TE could significantly discriminate significant fibrosis from mild fibrosis (P < 0.001). SWE exhibited a higher correlation with LSMs of liver fibrosis than TE (r = 0.65 and 0.50, P < 0.001). The diagnostic performance of SWE was better than that of TE for significant fibrosis (F > 2). The areas under the receiver operating characteristic curves of SWE and TE were 0.786 and 0.714, respectively. The optimal LSM cutoff values of SWE and TE were 9.05 kPa and 8.15 kPa, respectively.

CONCLUSION

Compared to the TE value, the SWE value was less affected by other factors. SWE may be more sensitive and precise than TE in predicting significant fibrosis (> F2) in CHB patients.

Asian consensus recommendations on optimizing the diagnosis and initiation of treatment of hepatitis B virus infection in resource-limited settings

Asia has an intermediate-to-high prevalence of and high morbidity and mortality from hepatitis B virus (HBV) infection. Optimization of diagnosis and initiation of treatment is one of the crucial strategies for lowering disease burden in this region. Therefore, a panel of 24 experts from 10 Asian countries convened, and reviewed the literature, to develop consensus guidance on diagnosis and initiation of treatment of HBV infection in resource-limited Asian settings. The panel proposed 11 recommendations related to diagnosis, pre-treatment assessment, and indications of therapy of HBV infection, and management of HBV-infected patients with co-infections. In resource-limited Asian settings, testing for hepatitis B surface antigen may be considered as the primary test for diagnosis of HBV infection. Pre-treatment assessments should include tests for complete blood count, liver and renal function, hepatitis B e-antigen (HBeAg), anti-HBe, HBV DNA, co-infection markers and assessment of severity of liver disease. Noninvasive tests such as AST-to-platelet ratio index, fibrosis score 4 or transient elastography may be used as alternatives to liver biopsy for assessing disease severity. Considering the high burden of HBV infection in Asia, the panel adopted an aggressive approach, and recommended initiation of antiviral therapy in all HBV-infected, compensated or decompensated cirrhotic individuals with detectable HBV DNA levels, regardless of HBeAg status or alanine transaminase levels. The panel also developed a simple algorithm for guiding the initiation of treatment in noncirrhotic, HBV-infected individuals. The recommendations proposed herein, may help guide clinicians, to optimize the diagnosis and improvise the treatment rates for HBV infection in Asia.

Impact of respiratory motion on liver stiffness measurements according to different shear wave elastography techniques and region of interest methods: a phantom study

Purpose

This study quantified the impact of respiratory motion on liver stiffness measurements according to different shear wave elastography (SWE) techniques and region of interest (ROI) methods, using liver fibrosis phantoms.

Methods

Three operators measured stiffness values in four phantoms with different stiffness on a moving platform with two SWE techniques (point-SWE [pSWE] and 2-dimensional SWE [2D-SWE]), three types of motion (static mode and moving mode at low and high speeds), and four ROI methods in 2D-SWE (circle, point, box, and multiple). The circular ROI method was used to compare the two SWE techniques. The occurrence of technical failure and unreliable measurements, stiffness values, and measurement time were evaluated.

Results

Technical failure was observed only in moving mode for pSWE and 2D-SWE (n=1 for both). Unreliable measurements were also only observed in moving mode and were significantly less common in 2D-SWE (n=1) than in pSWE (n=12) (P<0.001). No statistically significant differences in the technical failure rate or stiffness values were noted between the static and moving modes for both SWE techniques. The technical failure and unreliable measurement rates were not significantly different among the ROI methods for 2D-SWE. Stiffness values did not differ significantly according to the ROI method used in any moving mode. However, the multiple ROI method had significantly shorter measurement times than the circular ROI method for all moving modes.

Conclusion

2D-SWE may be preferable for evaluating liver fibrosis in patients with poor breath-hold. Furthermore, 2D-SWE with multiple ROIs enables rapid measurements, without affecting liver stiffness values.

Comparison of point and 2-dimensional shear wave elastography for the evaluation of liver fibrosis

PURPOSE

This study aimed to assess the technical performance of ElastQ Imaging compared with ElastPQ and to investigate the correlation between liver stiffness (LS) values obtained using these two techniques.

METHODS

This retrospective study included 249 patients who underwent LS measurements using both ElastPQ and ElastQ Imaging equipped on the same machine. The applicability, repeatability (coefficient of variation [CV]), acquisition time, and LS values were compared using the chi-square or Wilcoxon signed-rank tests. In the development group, the correlation between the LS values obtained by the two techniques was assessed with Spearman correlation coefficients and linear regression analysis. In the validation group, the agreement between the estimated and real LS values was evaluated using a Bland-Altman plot.

RESULTS

ElastQ Imaging had higher applicability (94.0% vs. 78.3%, P<0.001) and higher repeatability, with a lower median CV (0.127 vs. 0.164, P<0.001) than did ElastPQ. The median acquisition time of ElastQ Imaging was significantly shorter than that of ElastPQ (45.5 seconds vs. 96.5 seconds, P<0.001). The median LS value obtained using ElastQ Imaging was significantly higher than that obtained using ElastPQ (5.60 kPa vs. 5.23 kPa, P<0.001). The LS values between the two techniques exhibited a strong positive correlation (r=0.851, P<0.001) in the development group. The mean difference and 95% limits of agreement were 0.0 kPa (-3.9 to 3.9 kPa) in the validation group.

CONCLUSION

ElastQ Imaging may be more reliable and faster than ElastPQ, with strongly correlated LS measurements.

Accuracy of Transient Elastography Data Combined With APRI in Detection and Staging of Liver Disease in Pediatric Patients With Cystic Fibrosis

BACKGROUND & AIMS

Liver disease develops in 15%-72% of patients with cystic fibrosis, and 5%-10% develop cirrhosis or portal hypertension, usually during childhood. Transient elastography (TE) is a noninvasive method to measure liver stiffness. We aimed to validate its accuracy in detection of liver disease and assessment of fibrosis in children with cystic fibrosis.

METHODS

We performed a cross-sectional study to evaluate the accuracy of TE in analysis of liver disease in 160 consecutive children who presented with cystic fibrosis (9.0 ± 0.4 years old, 53% male) at a tertiary referral pediatric center in Australia, from 2011 through 2016. Patients were classified as having cystic fibrosis-associated liver disease (CFLD) or cystic fibrosis without liver disease (CFnoLD) based on clinical, biochemical, and imaging features. Fibrosis severity was determined from histologic analysis of dual-pass liver biopsies from children with CFLD, as the reference standard. Data from healthy children without cystic fibrosis (n = 64, controls) were obtained from a separate study. Liver stiffness measurements (LSMs) were made by Fibroscan analysis, using the inter-quartile range/median ≤30% of 10 valid measurements. Children with macronodularity or portal hypertension with heterogeneous changes on ultrasound without available biopsy were assigned to the category of stage F3-F4 fibrosis.

RESULTS

LSM was made reliably in 86% of children; accuracy increased with age. LSMs were significantly higher in children with CFLD (10.7 ± 2.4 kPa, n = 33) than with CFnoLD (4.6 ± 0.1 kPa, n = 105) (P < .0001) or controls (4.1 ± 0.1kPa) (P < .0001); LSMs were higher in children with CFnoLD than controls (P < .05). At a cut-off value of 5.55kPa, LSM identified children with CFLD with an area under the receiver operating characteristic (AUROC) curve of 0.82, 70% sensitivity, and 82% specificity (P < .0001). Classification and regression tree models that combined LSM and aspartate aminotransferase to platelet ratio index (APRI) identified children with CFLD with an AUROC curve of 0.89, 87% sensitivity, and 74% specificity (odds ratio, 18.6). LSMs correlated with fibrosis stage in patients with CFLD (r = 0.67, P = .0001). A cut-off value of 8.7kPa differentiated patients with stage F3-F4 fibrosis from patients with stage F1-F2 fibrosis (AUROC, 0.87; 75% sensitivity; 100% specificity, P=.0002). The combination of LSMs and APRI improved the differentiation of patients with F3-F4 fibrosis vs F1-F2 fibrosis (AUROC, 0.92; 83% sensitivity; and 100% specificity (P < .01).

CONCLUSIONS

LSMs made by TE accurately detect liver disease in children with cystic fibrosis; diagnostic accuracy increases when LSMs are combined with APRI. LSMs also differentiate between children with cystic fibrosis with mild-moderate fibrosis vs advanced fibrosis.

Evaluation and comparison of the diagnostic performance of routine blood tests in predicting liver fibrosis in chronic hepatitis B infection

Background & aims: Biopsy is the gold standard for staging liver fibrosis, but it may be accompanied by complications. As an alternative, non-invasive markers such as transient elastography (for liver fibrosis) and certain combinations of routine blood markers (liver function tests, full blood count) have been developed although their clinical significance remains controversial. Here, we compare the diagnostic values of non-invasive markers for liver fibrosis in patients with chronic hepatitis B infection. Methods: Transient elastography and routine laboratory tests were performed in 196 patients. Diagnostic performances were compared and were assessed based on the area under the curve (AUC) of a receiver operating characteristic (ROC) analysis. Results: Elevated GGT to platelet ratio (GPR), the fibrosis index FIB-4 [based on age, AST, platelets and ALT], platelet to lymphocyte ratio (PLR) and total bilirubin were independent predictors of liver stiffness defined by transient elastography (all P < 0.001). The AUCs of GPR in predicting both advanced fibrosis and cirrhosis were significantly larger than that of FIB-4 (P = 0.037 and P = 0.008, respectively) and AST-to-platelet ratio index (APRI) (P = 0.008 and P = 0.005). FIB-4, APRI and red cell volume distribution width-to-platelet ratio (RPR) had similar diagnostic values in discriminating different levels of liver fibrosis. Conclusions: GPR showed the best diagnostic value and RPR and PLR are easily available and inexpensive markers in evaluating fibrosis and cirrhosis. The diagnostic values of these laboratory markers are useful in diagnosing advanced fibrosis or cirrhosis, and in confirming the different levels of liver fibrosis.

Prospective Validation of Intra- and Interobserver Reproducibility of a New Point Shear Wave Elastographic Technique for Assessing Liver Stiffness in Patients with Chronic Liver Disease

Objective

To assess intra- and inter-observer reproducibility of a new point shear wave elastography technique (pSWE, S-Shearwave, Samsung Medison) and compare its accuracy in assessing liver stiffness (LS) with an established pSWE technique (Virtual Touch Quantification, VTQ).

Materials and Methods

Thirty-three patients were enrolled in this Institutional Review Board-approved prospective study. LS values were measured by VTQ on an Acuson S2000 system (Siemens Healthineer) and S-Shearwave on an RS-80A (Samsung Medison) in the same session, followed by two further S-Shearwave sessions for inter- and intra-observer variation at 8-hour intervals. The technical success rate (SR) and reliability of the measurements of both pSWE techniques were compared. The intra- and inter-observer reproducibility of S-Shearwave was determined by intraclass correlation coefficients (ICCs). LS values were measured by both methods of pSWE. The diagnostic performance in severe fibrosis (F ≥ 3) and cirrhosis (F = 4) was evaluated using the receiver operating characteristics curve analysis and the Obuchowski measure with the LS values of transient elastography as the referenced standard.

Results

The VTQ (100%, 33/33) and S-Shearwave (96.9%, 32/33) techniques did not display a significant difference in technical SR (p = 0.63) or reliability of LS measurements (96.9%, 32/33; 93.9%, 30/32, respectively, p = 0.61). The inter- and intra-observer agreement for LS measurements using the S-Shearwave technique was excellent (ICC = 0.98 and 0.99, respectively). The mean LS values of both pSWE techniques were not significantly different and exhibited a good correlation (r = 0.78). To detect F ≥ 3 and F = 4, VTQ and S-Shearwave showed comparable diagnostic accuracy as indicated by the following outcomes: areas under receiver operating characteristics curve (AUROC) = 0.87 (95% confidence intervals [CI] 0.70–0.96), 0.89 for VTQ (95% CI 0.74–0.97), respectively; and AUROC = 0.84 (95% CI 0.67–0.94), 0.94 (95% CI 0.80–0.99) for S-Shearwave (p > 0.48), respectively. The Obuchowski measures were similarly high for S-Shearwave and VTQ (0.94 vs. 0.95).

Conclusion

S-Shearwave shows excellent inter- and intra-observer agreement and diagnostic effectiveness comparable to VTQ in detecting LS.