Aspartate aminotransferase to platelet ratio index – a reliable predictor of therapeutic efficacy and improvement of Ishak score in chronic hepatitis B patients treated with nucleoside analogues

Novel predictive models using serum ceruloplasmin levels for hepatic steatosis in patients with chronic hepatitis B infection

AIMS

To evaluate the significance of serum ceruloplasmin (CP) to diagnosis hepatic steatosis (HS) in Chronic hepatitis B (CHB) patients.

METHODS

A total of 360 CHB patients with HS (n = 136) or without HS (n = 224) were included. Relationships between CP and HS degrees were analyzed by Spearman rank correlation. HS-predictive models including CP were constructed using multivariate logistic regression analysis and compared to other HS predicting indexes.

RESULTS

Serum CP were significantly higher in CHB patients with HS than in patients without HS (P < 0.001) and were positively correlated with HS degree (r = 0.487, P < 0.001). The area under the receiver-operating characteristic curves (AUCs) of using CP to predict HS (S ≥ 1), moderate and severe steatosis (S ≥ 2) and severe steatosis (S = 3) were 0.758, 0.794 and 0.883, respectively. Multivariate analysis showed that CP, age, high density lipoprotein (HDL) and hemoglobin were independent predictors of HS, and CP, body mass index and HDL were independent predictors of moderate and severe HS. Two novel indexes for predicting HS of CHB patients were generated. The AUC of HSCHB-1 (for S ≥ 1) and HSCHB-2 (for S ≥ 2) were 0.881 and 0.916 in the training group, and 0.865 and 0.841 in the validation group, respectively. HSCHB-1 was superior to HS index (P < 0.001), fatty liver disease index (P = 0.0043) and steatosis index of patients with hepatitis B virus infection (P = 0.0029) in predicting HS in CHB patients.

CONCLUSIONS

HS of CHB patients was positively associated with serum CP. HSCHB-1 and HSCHB-2 with inclusion of CP are two novel models for predicting HS in CHB patients.

Assessment of Hepatic Steatosis in Patients with Chronic Hepatitis B Using Fibroscan and its Relation to Insulin Resistance

Background & Aim:

Simple hepatic steatosis is a benign condition, but it may cause serious liver damage as it may lead to steatohepatitis, fibrosis and cirrhosis. The Controlled Attenuation Parameter (CAP) of fibroscan assesses hepatic steatosis. The aim of this work was to assess hepatic steatosis in patients with chronic hepatitis B infection using FibroScan and to detect its relation to insulin resistance.

Methods:

Seventy-seven patients with chronic HBV were enrolled in this study. Body mass index, complete lipid profile, fasting insulin, HOMA-IR, pelviabdominal ultrasound and fibroscan were assessed in all patients.

Results:

According to the presence of significant steatosis, seventy-seven patients enrolled in this study were divided into different groups, such as group I 47 patients (61.04%) with CHB virus infection with non-significant steatosis and group II 30 patients (38.96%) with CHB infection with significant steatosis. There was a statistically significant increase in fasting insulin and HOMA-IR in group II (p-value <0.001). CAP results ranged from 100-396 db/m with no significant difference in liver stiffness measurements in two studied groups (P value= 0.886). There was a significant positive correlation between the degree of hepatic steatosis measured by fibroscan and fasting insulin blood level, HOMA-IR, serum cholesterol and LDL. At cutoff > 222 db/m steatosis measured by fibroscan had a sensitivity of 63.33% and specificity of 82.35% for the detection of insulin resistance.

Conclusion:

In CHB infected patients, steatosis measurement by fibroscan was a strong predictor of Insulin Resistance (IR) and vice versa.

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.

Association between abdominal obesity and liver steatosis and fibrosis among patients with chronic hepatitis B measured by Fibroscan

The present cross-sectional study aimed to assess hepatic fibrosis in chronic hepatitis B (CHB) patients with abdominal obesity and to explore the associated indicators. A total of 615 CHB patients were enrolled and 287 of them had abdominal obesity. The liver stiffness value was measured using Fibroscan. The diagnosis of liver fibrosis was confirmed by a liver stiffness value of >7.4 kPa, and a value of >10.6 kPa was considered to indicate advanced liver fibrosis. The Fibroscan results suggested that the liver stiffness value in patients with abdominal obesity was significantly higher than that in patients without abdominal obesity (9.94±11.59 vs. 7.47±7.58 kPa; P=0.002). The proportions of patients with liver fibrosis and advanced liver fibrosis among patients with abdominal obesity were significantly higher than those among patients without abdominal obesity (P=0.011). Multivariate logistic regression analysis indicated that a high aspartate aminotransferase (AST) level [odds ratio (OR)=2.991; P<0.001], smoking (OR=2.002; P=0.019) and diabetes mellitus (OR=2.047; P=0.029) were independent indicators for liver fibrosis in CHB patients with abdominal obesity. Furthermore, a high AST level (OR=1.024; P<0.001), alcohol consumption (OR=1.994; P=0.032) and diabetes mellitus (OR=1.977; P=0.045) were independent indicators for advanced hepatic fibrosis. The indicators associated with liver steatosis included high body weight (OR=1.113; P<0.001) and high diastolic blood pressure (OR=1.079; P=0.002). In conclusion, the present study indicated that abdominal obesity significantly exacerbates liver fibrosis in CHB patients. For CHB patients with abdominal obesity and a risk of developing liver fibrosis, priority screening and timely intervention should be provided.

Dynamic Changes of the Aspartate Aminotransferase-to-Platelet Ratio and Transient Elastography in Predicting a Histologic Response in Patients With Chronic Hepatitis B After Entecavir Treatment

OBJECTIVES

To evaluate the dynamic changes of the aspartate aminotransferase (AST)-to-platelet ratio and transient elastography (FibroScan; Echosens, Paris, France) in predicting a histologic response in patients with chronic hepatitis B (CHB) after entecavir treatment.

METHODS

A total of 148 patients with CHB were enrolled. Patient information was collected. All patients received liver biopsy and FibroScan before and after 96 weeks of entecavir treatment.

RESULTS

Baseline liver biopsy results showed that there were 7 patients without liver fibrosis (fibrosis stage F0; 4.7%), 51 patients with mild liver fibrosis (F1; 34.5%), and 90 patients with advanced liver fibrosis (>F1; 60.9%). The liver stiffness value and AST-to-platelet ratio increased significantly as the METAVIR score of the patients increased from F0 to F4 (P < .001). After antiviral therapy for 96 weeks, the average liver stiffness value measured by FibroScan and the AST-to-platelet ratio showed a significant decrease. When we use a decreased liver stiffness value to predict a histologic response, the area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.61-0.79; P < .001), and the sensitivity and specificity were 74.3% and 68.8%, respectively. The decrease of the AST-to-platelet ratio also could predict the histologic response of patients with CHB; the area under the receiver operating characteristic curve was 0.77 (95% confidence interval, 0.69-0.86; P < .001) with sensitivity of 76.2% and specificity of 70.2%. A multivariate analysis indicated that a high hepatitis B virus DNA viral load (odds ratio, 1.44; P = .04) and high METAVIR score (odds ratio, 1.38; P = .02) were independent risk factors for the histologic response.

CONCLUSIONS

Both the AST-to-platelet ratio and FibroScan value can effectively predict a histologic response in patients with CHB during entecavir treatment. Therefore, they can be used to monitor these patients during antiviral treatment to avoid multiple liver biopsies.

Poor adherence is a contributor to viral breakthrough in patients with chronic hepatitis B

Objective

The objective of this study was to explore the risk factors of poor adherence of nucleoside analogs (NUC) treatment in chronic hepatitis B (CHB) patients and the virological changes in patients with poor adherence.

Subjects and methods

A total of 205 CHB patients were enrolled. The patients’ demographic data and family history were collected. NUC adherence was calculated every 12 weeks as follows: number of NUC tablets taken by the patients was divided by the number of NUC tablets prescribed. NUC adherence > 90% was defined as good adherence of NUC treatment.

Results

NUC adherence of male patients was significantly lower than that of female patients. Adherence among patients with previous NUC treatment was poorer than that of patients without previous NUC treatment. Multivariate analysis indicated that female gender (OR =0.367, P=0.013) was the protective factor for NUC adherence in CHB patients, while pretreatment with NUC was the risk factor for NUC adherence (OR =3.209, P=0.002). A total of six patients in the good adherence group experienced virological breakthroughs while 15 of 77 patients in the poor adherence group experienced virological breakthroughs (P=0.001). Similar trends were observed in NUC resistance. Four of the 128 patients with good adherence developed NUC resistance while nine of the 77 patients with poor adherence developed resistance (P=0.015). Multivariate analysis suggested that pretreatment with NUC (OR =3.133, P=0.031), NUC drugs (OR = 3.951, P=0.010), and adherence (OR =2.749, P=0.046) were independent risk factors associated with virological breakthroughs and that NUC drugs (OR =7.083, P=0.005) and poor adherence (OR =4.951, P=0.009) were independent risk factors for NUC resistance.

Conclusion

Male gender and pretreatment with NUC were risk factors associated with NUC adherence. Poor NUC adherence is more likely to induce virological breakthroughs and NUC resistance. For patients with poor NUC adherence, it is necessary to give timely education to improve treatment adherence.

Risk factors associated with nonalcohol fatty liver disease and fibrosis among patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is closely related to hepatic steatosis and fibrosis. The aim of this study was to analyze the occurrence of hepatic steatosis and fibrosis in patients with T2DM and to explore the risk factors.A total of 629 patients with T2DM were enrolled. Liver stiffness value (LSV) and controlled attenuation parameters (CAP) were measured using Fibroscan. Liver fibrosis was diagnosed when LSV was greater than 7.4 kPa, and advanced liver fibrosis was diagnosed when LSV was greater than 10.6 kPa. Hepatic steatosis diagnosis was made when CAP value was greater than 238 dB/m. Demographic information, physical examination data, and laboratory tests results were collected. The 629 patients were classified into 2 groups by the liver fibrosis and liver steatosis, and then the difference was analyzed.Among patients enrolled, 231 patients were diagnosed as liver fibrosis. The age of the patients in the fibrosis group was significantly greater than that in the non-fibrosis group, and similar trends were observed in the waist-hip ratio (WHR), systolic blood pressure, and diastolic blood pressure. The proportion of smoking and alcoholic consumption was significantly lower in patients with non-fibrosis group. A total of 426 patients were diagnosed with liver steatosis. Body mass index (BMI), WHR, systolic blood pressure, and diastolic blood pressure in patients with steatosis were significantly higher than those in non-steatosis group. We observed that the LSV (P = .042) and CAP value (P < .001) are positively correlated with metabolic syndrome components in T2DM patients. Older age (OR = 1.099, P = .001), high BMI (OR = 1.088, P = .003), low platelet level (OR = 0.996, P = .014), and smoking (OR = 1.653, P = .013) were independent risk factors of liver fibrosis among T2DM patients. High BMI (OR = 1.369, P < .001), high diastolic blood pressure (OR = 1.048, P < .001), and high gamma glutamyl transpeptidase (OR = 1.018, P = .009) were independent risk factors for liver steatosis among T2DM patients.This study suggested risk factors screening of liver fibrosis and steatosis. Timely intervention should be taken into consideration among high risk patients to prevent progress liver diseases.

Hepatoprotective effects of ethyl pyruvate against CCl4-induced hepatic fibrosis via inhibition of TLR4/NF-κB signaling and up-regulation of MMPs/TIMPs ratio

BACKGROUND AND AIM

Liver fibrosis is a worldwide clinical issue. It has been well established that liver fibrosis is characterized of excessive extracellular matrix (ECM) deposition in chronically damaged livers. Accumulating evidences have suggested that ethyl pyruvate (EP) is a potential useful agent for preventing from hepatic injury. The aim of this study was to evaluate the protective effects of the EP against liver fibrosis induced by carbon tetrachloride (CCl4) in rats.

METHOD

Rats were randomly divided into control group, CCl4 group and CCl4+EP group, which with and without EP administration. Liver fibrosis was evaluated by serum biochemical parameters levels, Masson's trichromic staining and immunohistochemistry. Q-RTPCR was used to indicate genes expression. ELISA was used to detect proteins level.

RESULTS

This study demonstrates that Toll-like receptors 4 (TLR4)/nuclear factor kappa B (NF-κB) signal is an important regulator of liver fibrosis while TLR4/NF-κB mRNA and protein levels reduced during HSCs activation. In addition, down-regulated high-mobility group box 1 (HMGB1) expression reduced NF-κB transcription and phosphorylation, which inhibited HSCs activation by blocking the TLR4 signal. Moreover, EP contributed to an increase in the ratio of matrix metalloproteinase (MMPs) to tissue inhibitor of matrix metalloproteinase (TIMPs), which might facilitate the degradation of the ECM. In CCl4-induced liver fibrosis rats, additional EP injection resulted in decreased ECM deposition and improved liver function.

CONCLUSION

In conclusion, the present findings indicated that EP might be an effective agent for anti-fibrotic therapy.

Neutrophil to Lymphocyte Ratio as Prognostic Indicator for Patients with Esophageal Squamous Cell Cancer

Background

This study aimed to evaluate the correlation between neutrophil to lymphocyte ratio (NLR) with overall survival (OS) of esophageal squamous cell carcinoma (ESCC) patients.

Method

Records of patients with diagnosed ESCC were reviewed. Leukocyte counts and patients' characteristics were extracted from their clinical records to calculate NLR. Correlation between NLR and baseline characteristics with overall survival (OS) was then analyzed using Cox regression. The patients were then separated into higher and lower NLR groups according to median NLR. OS was further compared between the 2 groups.

Results

A total of 1281 patients were included in the study. Cox regression analysis showed a significant correlation of NLR with OS of ESCC patients. The median pretreatment NLR was identified as 2.86. Higher NLR was associated with worse prognosis in terms of OS.

Conclusions

Pretreatment NLR is independently associated with OS of ESCC patients. Therefore, NLR may be used as a predictive indicator for pretreatment evaluation and adjustment of treatment regimen.

Predictors for advanced liver fibrosis in chronic hepatitis B virus infection with persistently normal or mildly elevated alanine aminotransferase

The aim of the present study was to evaluate the predictors for advanced liver fibrosis in patients with chronic hepatitis B virus (HBV) infection with persistently normal alanine aminotransferase (PNALT), or persistently or intermittently mildly elevated ALT (PIEALT). A total of 305 patients were included in the present study. Liver biopsies were evaluated using the METAVIR scoring system. Liver stiffness (LS) was measured using Fibroscan. Multivariate logistic regression and the area under the receiver operating characteristic curve (AUROC) were used to examine the diagnostic value of the predictors for advanced liver fibrosis. HBV DNA viral load in the PNALT group was significantly lower compared with the PIEALT group (4.57±1.68 vs. 5.71±1.69 log₁₀ IU/ml; P<0.001). Body mass index and LS were also significantly lower in the PNALT group compared with the PIEALT group (P<0.001). The proportion of patients with liver fibrosis was significantly higher in the PIEALT group compared with the PNATL group (P=0.001). High ALT levels were an independent predictor for liver fibrosis, with an odds ratio (OR) of 2.69 (P=0.002). Male sex (OR=0.34, P=0.007), high ALT levels (OR=2.37, P=0.029) and a high HBV DNA load (OR=1.39, P=0.005) were independent predictors for advanced liver fibrosis. The AUROC was 0.65 (P=0.003) when using ALT levels to predict advanced liver fibrosis. ALT levels at ≥0.88 upper limit of normal (ULN; 35 IU/l) were considered as positive for advanced liver fibrosis, the sensitivity and specificity were 87.8 and 47.4%, respectively. The AUROC was 0.64 (P=0.004) when using the HBV DNA value to predict advanced liver fibrosis. When an HBV DNA value of ≥4.99 log₁₀ IU/ml was considered as positive for advanced liver fibrosis, the sensitivity and specificity were 78.0 and 49.5%, respectively. The AUROC was 0.72 (P<0.001) when combining ALT, HBV DNA load and sex into a formulation to predict advanced liver fibrosis. When the formulation score at >-2.22 was considered as positive for advanced liver fibrosis, the sensitivity and specificity were 61.5 and 70.7%, respectively. Therefore, normal ALT levels do not always indicate the absence of hepatic fibrosis. A combination of ALT levels, sex and serum HBV DNA load may more effectively identify patients with CHB at high risk of developing fibrosis. These patients may benefit from liver biopsy.

A noninvasive diagnostic model to assess nonalcoholic hepatic steatosis in patients with chronic hepatitis B

OBJECTIVE

The objective of this study was to develop a noninvasive diagnostic test for nonalcoholic hepatic steatosis in patients with chronic hepatitis B (CHB) by using routinely available clinical markers.

METHODS

A retrospective study of patients with CHB, with or without hepatic steatosis (fatty change) who were diagnosed with controlled attenuation parameter (CAP) measured by transient elastography were included. Patient information was analyzed on lifestyle; laboratory tests, including serum lipid levels; blood pressure; blood uric acid; and medical history of type 2 diabetes mellitus (T2DM).

RESULTS

A total of 1312 patients were included in the study; 618 patients had confirmed hepatic steatosis. The CAP levels were significantly correlated with patient height (p < 0.001), weight (p < 0.001), waistline measurement (p < 0.001), hipline measurement (p < 0.001), and diastolic blood pressure (DBP) (p < 0.001). Multivariate logistic regression analysis resulted in the development of an equation for the diagnostic of simple steatosis: the fatty liver (FL) test. The area under the receiver operating characteristic (AUROC) curve of the FL test was 0.79 (p < 0.001) in the training group and 0.82 in the validation group. When the FL test was >-0.425, the sensitivity, specificity, positive likelihood ratio (LR) and negative LR were 74.72%, 72.12%, 2.68, and 0.35 respectively. The average FL test result was -0.54 ± 1.26 in patients with CHB without hypertension, and 0.42 ± 1.35, 1.12 ± 1.65, and 1.98 ± 1.22 in patients with hypertension grade 1, 2, and 3, respectively (p < 0.001).

CONCLUSION

This study has demonstrated a noninvasive test for hepatic steatosis in patients with CHB.