Systematic review with meta-analysis: direct comparisons of biomarkers for the diagnosis of fibrosis in chronic hepatitis C and B

Analysis of noninvasive methods in chronic hepatitis/human immunodeficiency virus mono- and co-infected patients with advanced fibrosis

OBJECTIVES

The aim of this study was to evaluate the degree of advanced fibrosis (F3/F4) using noninvasive methods [elastography, Fibrosis-4 (FIB4), and aspartate aminotransferase to platelet ratio index (APRI)] before and after treatment with new direct-acting antiviral agents (DAAs) in patients with hepatitis C virus (HCV), both in cases of co-infection (HCV/HIV) and single infection (HCV).

METHODS

This is a longitudinal study involving patients with HCV who are co-infected with HIV, who initiated HCV treatment between a positive anti-HCV test for more than 6 months and detectable HCV RNA. The control group consisted of patients with HCV infection without HIV co-infection, who received treatment during the same period as the co-infected patients.

RESULTS

A total of 75 co-infected and 87 mono-infected HCV patients were eligible. Before treatment, elastography and FIB4 methods showed a strong agreement (0.73), while after treatment, the agreement was moderate (0.58). Between elastography and APRI, a strong agreement was observed before treatment (0.66) and fair/weak agreement after treatment (0.30). Both FIB4 and APRI showed perfect agreement at both time points with values above 0.9 (0.97 for pretreatment and 0.92 for posttreatment). The use of DAAs was associated with high rates of sustained virological response and reduction in fibrosis degrees in the posttreatment period, as assessed through biomarkers and hepatic elastography.

CONCLUSION

The utilization of biomarkers in clinical practice for assessing hepatic fibrosis is an essential tool. Thus, for an accurate evaluation of hepatic fibrosis, particularly after HCV treatment, the use of elastography, rather than biomarkers alone, is more appropriate.

Diagnostic performance of FibroTest-ActiTest, transient elastography, and the fibrosis-4 index in patients with autoimmune hepatitis using histological reference

BACKGROUND

Noninvasive tests are crucial for the management and follow-up of patients with autoimmune hepatitis, but their validation is limited because of insufficient data.

AIM

To investigate the diagnostic performance of three fibrosis noninvasive tests [FibroTest, vibration-controlled transient elastography (VCTE), and the fibrosis-4 index (FIB-4) and two activity biomarkers (alanine aminotransferase (ALT) and ActiTest].

METHODS

This study enrolled 103 patients for whom liver biopsy, hepatic elastography results, and laboratory markers were available. Diagnostic performance was assessed with receiver operating characteristic (ROC) curves, the Obuchowski measure (OM), and the Bayesian latent class model.

RESULTS

FibroTest and VCTE outperformed FIB-4 in cases of significant fibrosis (≥ F2), with areas under the ROC curve of 0.83 [95% confidence interval (CI): 0.73-0.90], 0.86 (95%CI: 0.77-0.92), and 0.71 (95%CI: 0.60-0.80), respectively. The mean (standard error) OM values were 0.92 (0.01), 0.93 (0.01), and 0.88 (0.02) for FibroTest, VCTE, and FIB-4, respectively; FibroTest and VCTE performed comparably, and both were superior to FIB-4 (P = 0.03 and P = 0.005). The areas under the ROC curve values for activity biomarkers were 0.86 (95%CI: 0.76-0.92) for ActiTest and 0.84 (95%CI: 0.73-0.90) for ALT (P = 0.06). The OM values for ActiTest and ALT were 0.92 (0.02) and 0.90 (0.02), respectively (P = 0.005).

CONCLUSION

FibroTest and VCTE outperformed FIB-4 according to the OM. FibroTest-ActiTest facilitated the evaluation of both fibrosis and activity.

Performance Characteristics of a Calculated Index Control Method for the phi Multianalyte Assay with Algorithmic Analysis

BACKGROUND

Multianalyte assays with algorithmic analysis (MAAAs), such as the Prostate Health Index (phi), are increasingly utilized for generating disease risk scores. Currently, imprecision and bias in phi are not directly monitored by quality control (QC) assessment of the index but rather by QC assessment of individual components. This may not be adequately controlling for imprecision and bias in the calculated multicomponent phi value itself.

METHODS

Inter- and intra-assay phi precision was compared to precision of the individual component assays. QC measurements from total prostate-specific antigen (PSA), free PSA, and p2PSA were used to calculate a single calculated phi QC metric (PHIc). The frequency of QC failure of PHIc, relative to individual components QC by Westgard rules (13S and 22S), was determined. The effects of varying analyte component assay bias on the resulting PHIc metric were also examined.

RESULTS

Average measured phi imprecision (6.7% CV) was higher than individual phi analyte component imprecision (3.9-4.5% CV) across 2 Beckman Coulter Unicel DxI 800 instruments. A retrospective examination of PHIc QC over 84 quality control determinations was concurrently carried out for both PHIc and component assay failure patterns, which were dependent on SDs utilized for Westgard evaluation. Finally, reinforcing nonlinear changes in PHIc were observed in select cases of introduced simulated bias of individual component measurements.

CONCLUSIONS

An additional calculated phi QC measure can be introduced to monitor MAAA precision/bias, and in principle calculated index controls may represent a complementary supplemental QC method that could be applied to other MAAA indices.

Clinical- and Cost-Effectiveness of Liver Disease Staging in Hepatitis C Virus Infection: A Microsimulation Study

BACKGROUND

Liver disease assessment is a key aspect of chronic hepatitis C virus (HCV) infection pre-treatment evaluation but guidelines differ on the optimal testing modality given trade-offs in availability and accuracy. We compared clinical outcomes and cost-effectiveness of common fibrosis staging strategies.

METHODS

We simulated adults with chronic HCV receiving care at US health centers through a lifetime microsimulation across five strategies: (1) no staging or treatment (comparator), (2) indirect serum biomarker testing (Fibrosis-4 index [FIB-4]) only, (3) transient elastography (TE) only, (4) staged approach: FIB-4 for all, TE only for intermediate FIB-4 scores (1.45-3.25), and (5) both tests for all. Outcomes included infections cured, cirrhosis cases, liver-related deaths, costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). We used literature-informed loss to follow-up (LTFU) rates and 2021 Medicaid perspective and costs.

RESULTS

FIB-4 alone generated the best clinical outcomes: 87.7% cured, 8.7% developed cirrhosis, and 4.6% had liver-related deaths. TE strategies cured 58.5%-76.6%, 16.8%-29.4% developed cirrhosis, and 11.6%-22.6% had liver-related deaths. All TE strategies yielded worse clinical outcomes at higher costs per QALY than FIB-4 only, which had an ICER of $12 869 per QALY gained compared with no staging or treatment. LTFU drove these findings: TE strategies were only cost-effective with no LTFU. In a point-of-care HCV test-and-treat scenario, treatment without any staging was most clinically and cost-effective.

CONCLUSIONS

FIB-4 staging alone resulted in optimal clinical outcomes and was cost-effective. Treatment for chronic HCV should not be delayed while awaiting fibrosis staging with TE.

Imaging-based noninvasive liver disease assessment for staging liver fibrosis in chronic liver disease: A systematic review supporting the AASLD Practice Guideline

BACKGROUND AND AIMS

Transient elastography (TE), shear wave elastography, and/or magnetic resonance elastography (MRE), each providing liver stiffness measurement (LSM), are the most studied imaging-based noninvasive liver disease assessment (NILDA) techniques. To support the American Association for the Study of Liver Diseases guidelines on NILDA, we summarized the evidence on the accuracy of these LSM methods to stage liver fibrosis (F).

APPROACH AND RESULTS

A comprehensive search for studies assessing LSM by TE, shear wave elastography, or MRE for the identification of significant fibrosis (F2-4), advanced fibrosis (F3-4), or cirrhosis (F4), using histopathology as the standard of reference by liver disease etiology in adults or children from inception to April 2022 was performed. We excluded studies with <50 patients with a single disease entity and mixed liver disease etiologies (with the exception of HCV/HIV coinfection). Out of 9447 studies, 240 with 61,193 patients were included in this systematic review. In adults, sensitivities for the identification of F2-4 ranged from 51% to 95%, for F3-4 from 70% to 100%, and for F4 from 60% to 100% across all techniques/diseases, whereas specificities ranged from 36% to 100%, 74% to 100%, and 67% to 99%, respectively. The largest body of evidence available was for TE; MRE appeared to be the most accurate method. Imaging-based NILDA outperformed blood-based NILDA in most comparisons, particularly for the identification of F3-4/F4. In the pediatric population, imaging-based NILDA is likely as accurate as in adults.

CONCLUSIONS

LSM from TE, shear wave elastography, and MRE shows acceptable to outstanding accuracy for the detection of liver fibrosis across various liver disease etiologies. Accuracy increased from F2-4 to F3-4 and was the highest for F4. Further research is needed to better standardize the use of imaging-based NILDA, particularly in pediatric liver diseases.

Comparison of different noninvasive scores for assessing hepatic fibrosis in a cohort of chronic hepatitis C patients

The continuous search for simple, noninvasive methods for assessing liver fibrosis remains very important to help risk-stratify and follow-up patients with chronic hepatitis C virus (HCV). This study aimed to evaluate the diagnostic performance and accuracy of six serological noninvasive scores for the assessment of liver fibrosis in comparison to liver histopathology. This retrospective cohort study included data from 19501 patients with chronic HCV infection who had liver biopsies as an HCV treatment prerequisite within the Egyptian national HCV treatment program. Six noninvasive scores (FIB-4, APRI, King's score, Fibro-Q, fibrosis index, Fibro-α score) were evaluated and compared to liver histopathology data in assessing different stages of liver fibrosis. The diagnostic performance for each score was assessed using the area under the receiver-operating characteristic curve (AUROC). All six noninvasive scores were statistically significant for predicting different stages of liver fibrosis. Four scores (FIB-4, King's score, APRI, and Fibro Q) had a better diagnostic performance for predicting different fibrosis stages. FIB-4, followed by the King's score, performs better in identifying patients with advanced fibrosis at cutoffs of 2.01 and 16.7, respectively, with AUROC of 0.71 for both, and in predicting cirrhosis at cutoffs of 2.21 and 17.4, respectively with AUROC 0.82 for both. Using noninvasive scores for fibrosis assessment is very important, especially in limited resource settings, to rapidly stratify patients who need more specialized care.

[Serological Markers to Assess Liver Fibrosis and Their Roles]

Chronic liver disease is a significant public health issue worldwide, with the degree of liver fibrosis and its progression significantly influencing the treatment and prognosis. A liver biopsy is the standard diagnostic method, but it is invasive and presents various issues. Therefore, numerous non-invasive diagnostic methods have been developed. Serum markers are categorized into indirect markers, which reflect liver damage, inflammation, or functional changes, and direct markers, which measure the components released into the bloodstream during fibrosis. In addition, various kinds of formulas that combined direct/indirect markers and demographic variables were developed and validated with encouraging outcomes. Nevertheless, despite their convenience, serum indicators require cautious interpretation because they are affected by a number of factors. More research will be needed to determine if the clinical course of chronic liver disease under a disease-specific treatment could be monitored appropriately using serological markers.

[Non-Invasive Test for Assessment of Liver Fibrosis in Chronic Hepatitis B]

Chronic hepatitis B (CHB) is a high-risk condition that requires continuous monitoring and appropriate management during the natural course of the disease. In particular, the assessment of liver fibrosis is crucial for determining the optimal timing of antiviral therapy, evaluating the treatment response, and predicting the occurrence and prognosis of hepatocellular carcinoma (HCC) in the management of CHB. Although a liver biopsy is the gold standard for diagnosing liver inflammation, steatosis, and fibrosis, there has been a growing trend in the use of non-invasive tests, such as serum biomarkers, transient elastography, and shear wave elastography in CHB patients. This review provides a summary of the key research findings on the use of serum biomarkers and transient elastography in assessing liver fibrosis, monitoring the disease progression, and predicting the prognosis of CHB patients, with an emphasis on their clinical applicability.

Prognostic Value of Fibrosis 4 (FIB-4) Index in Sepsis Patients

BACKGROUND

Sepsis remains a major health challenge worldwide, characterized by a dysregulated host response to infection, leading to high mortality and morbidity in intensive care units (ICUs). The Fibrosis 4 (FIB-4) index, originally developed to assess liver fibrosis in hepatitis C patients, has recently been explored for its potential prognostic value in sepsis patients.

METHOD

this study retrospectively analyzed 309 sepsis patients admitted to the Internal Medicine and An-aesthesia ICUs between 12 December 2021 and 15 December 2023 to investigate the relationship between FIB-4 levels, the Acute Physiology and Chronic Health Evaluation (APACHE), the Sequential Organ Failure Assessment (SOFA), and clinical outcomes.

RESULTS

This study found that higher FIB-4 measurements were statistically significantly associated with increased 28-day mortality, with a cut-off value of 4.9, providing a sensitivity of 54.92% and specificity of 74.25%. Logistic regression analysis indicated that elevated FIB-4 levels were a significant predictor of early mortality, suggesting that the FIB-4 index could serve as a valuable prognostic tool in assessing the severity and prognosis of sepsis patients.

CONCLUSIONS

by elucidating the potential role of the FIB-4 index in sepsis prognosis, this study contributes to the ongoing efforts to improve risk stratification and enhance patient care in sepsis management.

Prediction model of hepatitis B virus-related hepatocellular carcinoma in patients receiving antiviral therapy

Chronic hepatitis B virus (HBV) infection, which ultimately leads to liver cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC), remains a significant disease burden worldwide. Despite the use of antiviral therapy (AVT) using oral nucleos(t)ide analogs (NUCs) with high genetic barriers, the risk of HCC development cannot be completely eliminated. Therefore, bi-annual surveillance of HCC using abdominal ultrasonography with or without tumor markers is recommended for at-risk populations. For a more precise assessment of future HCC risk at the individual level, many HCC prediction models have been proposed in the era of potent AVT with promising results. It allows prognostication according to the risk of HCC development, for example, low-vs. intermediate-vs. high-risk groups. Most of these models have the advantage of high negative predictive values for HCC development, allowing exemption from biannual HCC screening. Recently, non-invasive surrogate markers for liver fibrosis, such as vibration-controlled transient elastography, have been introduced as integral components of the equations, providing better predictive performance in general. Furthermore, beyond the conventional statistical methods that primarily depend on multi-variable Cox regression analyses based on the previous literature, newer techniques using artificial intelligence have also been applied in the design of HCC prediction models. Here, we aimed to review the HCC risk prediction models that were developed in the era of potent AVT and validated among independent cohorts to address the clinical unmet needs, as well as comment on future direction to establish the individual HCC risk more precisely.

FibroMeter scores are predictive noninvasive markers of advanced and significant liver fibrosis in patients with chronic viral hepatitis or metabolic dysfunction-associated steatotic liver disease

Background

FibroMeter and FibroMeter vibration-controlled transient elastography (FibroMeter VCTE) were assessed in a Greek cohort of patients with chronic viral hepatitis (CVH) B and C or metabolic dysfunction-associated steatotic liver disease (MASLD) to evaluate their accuracy in predicting advanced liver fibrosis against other well-validated noninvasive markers.

Methods

Group 1: n=83 CVH and group 2: n=38 MASLD patients underwent liver biopsy and transient elastography (TE) on the same day as sera collection. FibroMeter scores APRI and FIB-4 were calculated in all 121 patients, while MASLD fibrosis score (MFS) was also calculated in group 2.

Results

In CVH, FibroMeter VCTE performed equivalently to TE and better than the other markers in predicting advanced (≥F3) and significant (≥F2) fibrosis (area under the receiver operating characteristic curve [AUC] 0.887, P<0.001 for F3; AUC 0.766 P<0.001 for F2). FibroMeter Virus (cutoff 0.61) had lower sensitivity (20%) but performed equivalently to APRI and FIB-4. In MASLD, all markers but APRI performed equivalently in predicting advanced fibrosis. FibroMeter VCTE >0.2154 had the same sensitivity (100%) and specificity (81%) as TE (cutoff >7.1 kPa). FibroMeter MASLD >0.25 performed equivalently to MFS and FIB4, but with higher specificity (100%). Both FibroMeter and FibroMeter VCTE correlated with liver histology but not with liver enzymes.

Conclusions

FibroMeter VCTE predicts accurately advanced fibrosis in CVH and MASLD, irrespectively of transaminase levels. FibroMeter Virus can be applied only as an alternative marker in CVH, while FibroMeter MASLD performs equally to TE and calculated scores (MFS, FIB-4) in predicting advanced fibrosis in MASLD patients.

Non-invasive fibrosis markers for assessment of liver fibrosis in chronic hepatitis delta

Assessment of liver fibrosis by non-invasive means is clinically important. Studies in chronic hepatitis delta (CHD) are scarce. We evaluated the performance of eight serum fibrosis markers [fibrosis-4 score (FIB-4), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AAR), age-platelet index (API), AST-to platelet-ratio-index (APRI), Goteborg University Cirrhosis Index (GUCI), Lok index, cirrhosis discriminant score (CDS) and Hui score] in CHD and chronic hepatitis B (CHB). Liver stiffness was assessed by transient elastography (TE) in CHD. The ability of fibrosis markers to detect significant fibrosis and cirrhosis were evaluated in 202 CHB and 108 CHD patients using published and new cut-offs through receiver operating characteristics (ROC) analysis. The latter was also applied to obtain cut-offs for TE. APRI, Fib-4, API and Hui score were assessed for significant fibrosis, and APRI, GUCI, Lok index, CDS and AAR for cirrhosis determination. Fibrosis markers displayed weak performance in CHB for significant fibrosis with area under ROC (AUROC) curves between 0.62 and 0.71. They did slightly better for CHD. TE displayed an AUROC of 0.92 and performed better than serum fibrosis markers (p < 0.05 for fibrosis markers). For cirrhosis determination, CDS and Lok Index displayed an AUROC of 088 and 0.89 in CHB and GUCI, Lok index and APRI displayed AUROCs around 0.90 in CHD. TE displayed the best AUROC (0.95). Hence TE is superior to serum fibrosis markers for diagnosing significant liver fibrosis and cirrhosis. GUCI, Lok index and APRI displayed a reasonable performance in CHD, which needs further confirmation.

Autoimmune Hepatitis and Fibrosis

Autoimmune hepatitis (AIH) is a chronic immune-inflammatory disease of the liver, generally considered a rare condition. The clinical manifestation is extremely varied and can range from paucisymptomatic forms to severe hepatitis. Chronic liver damage causes activation of hepatic and inflammatory cells leading to inflammation and oxidative stress through the production of mediators. This results in increased collagen production and extracellular matrix deposition leading to fibrosis and even cirrhosis. The gold standard for the diagnosis of fibrosis is liver biopsy; however, there are serum biomarkers, scoring systems, and radiological methods useful for diagnosis and staging. The goal of AIH treatment is to suppress fibrotic and inflammatory activities in the liver to prevent disease progression and achieve complete remission. Therapy involves the use of classic steroidal anti-inflammatory drugs and immunosuppressants, but in recent years scientific research has focused on several new alternative drugs for AIH that will be discussed in the review.

Diagnostic Accuracy of Red Cell Distribution Width to Platelet Ratio for Detection of Liver Fibrosis Compared with Fibroscan in Chronic Hepatitis B Egyptian patients

Background and Aims:

The decision to treat chronic hepatitis B Virus infection (CHB) may necessitate an assessment of the degree of liver fibrosis. Guidelines recommend Fibroscan examination in such cases. However, it is costly and not widely available. Red cell distribution width (RDW) and platelet count are simple parameters obtained from the blood pictures; and their ratio RDW to platelet ratio (RPR) was claimed to correlate with liver fibrosis. We aimed to assess the ability of RPR to replace the costly fibroscan in the detection of significant fibrosis in chronic hepatitis B patients.

Patients and Methods:

This cross-sectional study was conducted in the Tropical medicine department, Tanta University, Egypt, between December 2018 and September 2019. One hundred and twenty-five patients with CHB were included and divided according to the fibroscan examination into: Group I: patients with no significant fibrosis (n=66), Group II: patients with significant (≥ F2) fibrosis (n=59). RPR was calculated for all patients and tested against Fibroscan results.

Results:

Both groups were matched in regards to age, sex, viral load, and steatosis. There was a significant positive correlation between the degree of stiffness measured by FibroScan in patients with a significant degree of fibrosis and serum bilirubin, a quantitative polymerase chain reaction of hepatitis B virus DNA (HBV DNA PCR), and fibrosis-4 score (FIB-4 score) (P value= 0.020, 0.049, and 0.0402, respectively). However, RPR was not correlated to the degree of fibrosis in fibroscan examination.

Conclusions:

The accuracy of RDW to platelet ratio (RPR) for the detection of fibrosis in CHB patients is questionable. FIB-4 is correlated with liver stiffness measurement (LSM) in patients with significant fibrosis (F2 or more). Neither RPR, AST to Platelet Ratio Index (APRI) or FIB4 can replace fibroscan for grading of fibrosis in CHB patients for evaluation to start therapy.

Different impacts of common risk factors associated with thrombocytopenia in patients with hepatitis B virus and hepatitis C virus infection

BACKGROUND

Thrombocytopenia is a common extrahepatic manifestation in chronic liver disease. However, there have been rare studies of impacts of risk for hepatitis C virus-associated thrombocytopenia (HCV-TP) and hepatitis B virus-associated thrombocytopenia (HBV-TP). The aim of this study is to evaluate different impacts of risk factors for HCV-TP and HBV-TP.

METHODS

We retrospectively collected 1803 HCV patients and 1652 HBV patients to examine the risk factors for time to moderate and severe thrombocytopenia (platelet counts <100 × 109/L and <50 × 109/L, respectively) by Cox proportional hazards models. Moreover, we prospectively enrolled 63 HCV-TP patients, 11 HBV-TP patients, and 27 HCV controls to detect specific antiplatelet antibodies by enzyme-linked immunosorbent assay and analyze their effects.

RESULTS

Prevalence of platelet <100 × 109/L was 11.86% and 6.35% in HCV and HBV patients without cancer history, respectively. HCV-to-HBV incidence rate ratio for thrombocytopenia was 6.95. Initial thrombocytopenia was the most significant risk factor for HCV-TP and HBV-TP regardless of thrombocytopenia severity. Splenomegaly and cirrhosis were significant risk factors for moderate, but not severe HCV-TP. Hyperbilirubinemia was an important moderate and severe HBV-TP risk factor. Antiplatelet antibodies were correlated with HCV-TP severity, of which anti-glycoprotein IIb/IIIa antibody being associated with smaller spleen size. The antiplatelet autoantibody might contribute to thrombocytopenia either independently or with splenomegaly as the important risk in HCV-TP patients without advanced cirrhosis.

CONCLUSION

HCV was associated with higher thrombocytopenia incidence than HBV. Thrombocytopenia risk factors varied with virus type and severity. Different management for HCV-TP and HBV-TP was suggested.

External Validation of LCR1-LCR2, a Multivariable Hepatocellular Carcinoma Risk Calculator, in a Multiethnic Cohort of Patients With Chronic Hepatitis B

Background and Aims

The liver cancer risk test (LCR1-LCR2) is a multianalyte blood test combining proteins involved in liver cell repair (apolipoprotein A1, haptoglobin), hepatocellular carcinoma (HCC) risk factors (gender, age, gamma glutamyl transpeptidase), a marker of fibrosis (alpha2-macroglobulin), and alpha-fetoprotein, a specific marker of HCC. The aim was to externally validate LCR1-LCR2 in hepatitis B.

Methods

Preincluded patients were from the Hepather cohort, a multicenter, multiethnic prospective study in 6071 patients. The coprimary study outcome was the negative predictive value of LCR1-LCR2 at 5 years for the occurrence of HCC and survival without HCC according to the predetermined LCR1-LCR2 cutoffs, adjusted for risk covariables and for chronic hepatitis B treatment and quantified using time-dependent Cox proportional hazards models. A post hoc analysis compared the number of patients needed to screen one cancer by LCR1-LCR2 and PAGE-B.

Results

A total of 3520 patients, 191 (5.4%) with cirrhosis, with at least 1 year of follow-up were included. A total of 76 HCCs occurred over a median (interquartile range) of 6.0 years (4.8-7.3) of follow-up. Among the 3367 patients with low-risk LCR1-LCR2, the 5-year negative predictive value was 99.3% (95% confidence interval = 99.0-99.6), with a significant Cox hazard ratio (6.4, 3.1-13.0; P < .001) obtained after adjustment for exposure to antivirals, age, gender, geographical origin, HBe-Ag status, alcohol consumption, and type-2 diabetes. LCR1-LCR2 outperformed PAGE-B for number of patients needed to screen mean (95% CI), 8.5 (3.2-8.1) vs 26.3 (17.5-38.5; P < .0001), respectively.

Conclusion

The performance of LCR1-LCR2 to identify patients with chronic hepatitis B at very low risk of HCC at 5 years was externally validated. ClinicalTrials.gov: NCT01953458.

Gene therapy: Practical aspects of implementation

The first wave of gene therapies for haemophilia submitted for regulatory review utilize a liver-directed approach in which a functional gene copy of factor VIII (FVIII) or factor IX (FIX) is packaged inside a recombinant adeno-associated viral vector (rAAV). Following a single treatment event, these particles are taken up into liver cells, where the rAAV uncoats and delivers the DNA to the nucleus of the cell, where genetic elements that accompany the gene allow for efficient expression and secretion of FVIII or FIX protein into the plasma. An immune response to the vector capsid has been manifest by elevations in common liver enzymes that must be diligently followed postinfusion for weeks and months afterward and if signs of toxicity appear, will trigger a course of immunosuppression. Despite this, the studies have shown that this works in the great majority of individuals and the immunosuppression course is either avoided or short-lived for many. Optimal outcomes in the haemophilia population will be dependent on proper screening assessment and maintenance of liver health prior to consideration of gene therapy, close short-term follow up and implementation of immunomodulatory strategies to identify and manage liver toxicity and preserve durable transgene expression. This review proposes best practices to assist clinical teams with overcoming the challenges this platform of therapy poses to the traditional clinical care models and infrastructure within the haemophilia treatment centres (HTCs) who will be coordinating the patient's journey through this potentially transformative therapy.

Liver fibrosis quantification

Liver fibrosis (LF) is the wound healing response to chronic liver injury. LF is the endpoint of chronic liver disease (CLD) regardless of etiology and the single most important determinant of long-term liver-related clinical outcomes. Quantification of LF is important for staging, to evaluate response to treatment and to predict outcomes. LF is traditionally staged by liver biopsy. However, liver biopsy is invasive and suffers from sampling errors when biopsy size is inadequate; therefore, non-invasive tests (NITs) have found important roles in clinical care. NITs include simple laboratory-based serum tests, panels of serum tests, and imaging biomarkers. NITs are validated against the liver biopsy and will be used in the future for evaluation of nearly all CLDs with invasive liver biopsy reserved for some cases. Both serum tests and some imaging biomarkers such as elastography are currently used clinically as surrogate markers for LF. Several other imaging biomarkers are still considered research and awaiting clinical application in the future. As the evaluation of imaging biomarkers will likely become the norm in the future, understanding pathogenesis of LF is important. Knowledge of properties measured by imaging biomarkers and its correlation with LF is important to understand the application of NITs by abdominal radiologists. In this review, we present a brief overview of pathogenesis of LF, spatiotemporal evolution of LF in different CLD, and severity assessment with liver biopsy. This will be followed by a brief discussion on properties measured by imaging biomarkers and their relationship to the LF.

FibroMeter scores for the assessment of liver fibrosis in patients with autoimmune liver diseases

INTRODUCTION AND OBJECTIVES

We assessed FibroMeter virus (FMvirus) and FibroMeter vibration-controlled transient elastography (FMVCTE) in 134 patients with autoimmune liver diseases [ALD, autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC)], in order to assess new potential non-invasive biomarkers of liver fibrosis in patients with ALD, as similar data are missing.

PATIENTS AND METHODS

The following groups were included: group 1: n = 78 AIH; group 2: n = 56 PBC. FMvirus and FMVCTE were determined in all 134 patients who underwent liver biopsy and TE the same day with sera collection. In addition, APRI and FIB-4 scores were calculated.

RESULTS

The AUCs for TE and FMVCTE were significantly better (0.809; p < 0.001 and 0.772; p = 0.001, respectively for AIH and 0.997; p < 0.001 and 1; p < 0.001, for PBC) than the other three markers in predicting ≥ F3 fibrosis irrespective of the biochemical activity. FMVCTE and TE had good diagnostic accuracy (75.6% and 73%, respectively) for predicting severe fibrosis in AIH and performed even better in PBC (94.6% and 96.4%, respectively). The cut-offs of TE and FMVCTE had the best sensitivity and specificity in predicting ≥ F3 fibrosis in both AIH and PBC.

CONCLUSIONS

FMVCTE seems to detect severe fibrosis equally to TE in patients with ALD but with better specificity. Biochemical disease activity did not seem to affect their diagnostic accuracy in ALD and therefore, could be helpful for the assessment of fibrosis, especially if they are performed sequentially (first TE with the best sensitivity and then FMVCTE with the best specificity).

Hepcidin-to-ferritin ratio: A potential novel index to predict iron overload-liver fibrosis in ß-thalassemia major

OBJECTIVES

We aimed to determine a threshold cutoff for hepcidin, ferritin, and the hepcidin-to-ferritin ratio in the diagnosis of liver fibrosis caused by iron overload in chronic hepatitis C virus (HCV)-free ß-thalassemia major patients .

METHODS

This 1:1-matched case-control study included 102 individuals (3-30 yr.); 51 ß-thalassemia major patients with iron overload , and 51 apparently healthy individuals.

RESULTS

The highest areas under the receiver operating characteristic curves (AUC-ROCs) for the diagnosis of patients vs. controls had overlapping 95% confidence intervals (CIs): serum hepcidin (0.758; 0.64-0.87; P ˂ 0.001), serum ferritin (1.000; 1.00-1.00; P˂0.001), and the hepcidin/ferritin ratio (1.000; 1.00-1.00; P˂0.001). For differentiation of patients with liver fibrosis stages of F0-F1 vs. F2-F4 and F0-F1 vs. F3-F4, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with P-values˂0.001 were the only statistically significant parameters, while the AUC-ROCs of the hepcidin/ferritin ratio (0.631, P=0.188 and 0.684, P=0.098) exhibited 90% and 89.5% sensitivity, respectively, in staging liver fibrosis.

CONCLUSION

Our results showed that the hepcidin/ferritin ratio is as effective as the APRI and maybe a better predictor for the diagnosis of liver fibrosis and discriminating its stages, with excellent sensitivity and specificity compared to its components.

Diagnostic accuracy of red blood cell distribution width to platelet ratio for predicting liver fibrosis in patients with chronic hepatitis B: A meta-analysis

OBJECTIVE

This study aims to systematically review the performance of red blood cell distribution width to platelet ratio (RPR) in the diagnosis of significant or advanced fibrosis, and cirrhosis associated with Hepatitis B virus (HBV).

METHODS

The relevant studies were comprehensively searched in English databases such as Web of Science, PubMed, EMBASE, Cochrane Library, as well as Chinese databases such as China National Knowledge Infrastructure, Wanfang Data from the inception to March 2021. Accuracy of RPR in diagnosing significant or advanced fibrosis and liver cirrhosis was assessed by area under the curve (AUC), pooled sensitivity and specificity, as well as positive and negative likelihood ratios. Stata 15.0 software was applied to analyze the data.

RESULTS

In total, 13 literature met the requirements, including patients with significant fibrosis (n=1890), advanced fibrosis (n=645), and cirrhosis (n=499). The prevalence rates of significant fibrosis, advanced fibrosis and cirrhosis were 49.31% (range: 17.25%-84.21%), 37.07% (range: 9.60%-58.20%) and 2.18% (range: 2.78%-44.19%), respectively. The AUCs for predicting significant fibrosis, advanced fibrosis, and cirrhosis by RPR were 0.73 (95%CI: 0.69-0.76),0.80 (95%CI: 0.77-0.84) and 0.80 (95%CI: 0.76-0.83), respectively.

CONCLUSION

RPR is of some diagnostic value to the prediction of HBV-related significant fibrosis, advanced fibrosis and cirrhosis.This conclusion is urgently needed to be verified by further multi-center studies of large sample size and rigorous design.

Prospective external validation of a new non-invasive test for the diagnosis of non-alcoholic steatohepatitis in patients with type 2 diabetes

BACKGROUND

One of the unmet needs in patients with type 2 diabetes mellitus (T2DM) is the prediction of non-alcoholic liver disease by non-invasive blood tests, for each of the three main histological features, fibrosis, non-alcoholic steatohepatitis (NASH) and steatosis.

AIMS

To validate externally the performances of a recent panel, Nash-FibroTest, for the assessment of the severity of fibrosis stages, NASH grades and steatosis grades.

METHODS

We prospectively analysed 272 patients with T2DM. Standard definitions of stages and grades were used, and analyses were centralised and blinded. The performances of the FibroTest, NashTest-2 and SteatoTest-2 were assessed using the Obuchowski measure (OM), the main outcome recommended as a summary measure of accuracy includeing all pairwise stages and grades comparisons, which is not provided par the extensively used binary area under the ROC curve.

RESULTS

The diagnostic performance of each component of the panel was significant. OM (SE; significance) of the FibroTest, the NashTest-2 and the SteatoTest-2 was 0.862 (0.012; P < 0.001), 0.827 (0.015; P < 0.001) and 0.794 (0.020; P < 0.01), respectively. For ballooning and lobular inflammation, OM was 0.794 (0.021; P < 0.001) and 0.821 (0.017; P < 0.001), respectively. In a post hoc analysis the FibroTest outperformed VCTE by 4.1% (2.5-6.5; P < 0.001) for reliability, with a non-significant difference for OM for fibrosis staging, 0.859 (0.012) for FibroTest vs 0.870 (0.009) for VCTE.

CONCLUSIONS

From a single blood sample, the panel provides non-invasive diagnosis of the stages of fibrosis, and the grades of NASH and steatosis in patients with T2DM.

TRIAL REGISTRATION NUMBER

NCT03634098.

Accuracy comparison of MR elastography and biological markers in detecting liver fibrosis and predicting postoperative ascites

BACKGROUND

This retrospective study aimed to compare the discriminative performance between magnetic resonance elastography (MRE) and biological markers in detecting liver fibrosis and in predicting postoperative ascites (PA).

METHODS

We enrolled 77 patients consecutively who underwent hepatectomy between March 2017 and June 2019. Liver fibrosis was histopathologically graded using the METAVIR scoring system as reference. Discriminative performance of non-invasive assessments in detecting different stages of liver fibrosis and predicting PA was evaluated by receiver-operator curve analysis.

RESULTS

The concordance indices (C-indices) for MRE and biological markers for detecting significant fibrosis (≥F2) and cirrhosis (F4) were: MRE, 0.84 and 0.86; Wisteria floribunda agglutinin + Mac-2 binding protein (WM2BP), 0.63 and 0.71; Hyaluronic acid (HA), 0.72 and 0.75; 7 S-type 4 collagen (T4C), 0.61 and 0.66; APRI, 0.76 and 0.83; and Fib-4, 0.75 and 0.76. Univariable logistic analysis for predicting PA showed that C-indices were 0.751 (p = 0.007), 0.798 (p = 0.106), 0.771 (p = 0.050), 0.674 (p = 0.855), 0.655 (p = 0.263), and 0.560 (p = 0.640) for MRE, WM2BP, Fib-4, HA, APRI, and T4C, respectively.

CONCLUSION

MRE has a higher diagnostic performance than biological markers in detecting the stages of liver fibrosis and is a predictor for PA after hepatectomy.

Comparison between shear wave elastography and serological findings for the evaluation of fibrosis in chronic liver disease

Aim: In this study, we sought to examine the optimal cutoff values for predicting different stages of liver fibrosis, and to determine the level of agreement between shear wave elastography and aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 index (FIB-4) scores in patients with chronic liver disease. Methodology: A descriptive, cross-sectional study was performed at the Radiology Department of Shaukat Khanum Memorial Hospital Lahore from 1 Jun 2019 until 1 June 2020. FIB-4 and APRI scores were determined by the following formula: FIB-4 = (age × AST) ÷ (platelet count × (√ (ALT)) and APRI = (AST÷AST upper limit of normal) ÷ platelet × 100. Data was analyzed with the help of SPSS version 24.0 and Microsoft Excel 2013. Results: Eighty individuals were conveniently selected, of which 62.5% were men and 37.5% were women. The mean age of the subjects was 43.47 SD ± 13.85 years. APRI and FIB-4 scores predicted F4 patients using the cutoff values of 0.47 (Sn. 72%, Sp. 70%) and 1.27 (Sn. 78%, Sp. 73%), respectively. The cutoff values of 0.46 for APRI and 1.27 for FIB-4 predicted F3–F4 patients (Sn. 74% and 77%; Sp. 76% and 76%), respectively. To predict F1–F4 compared to F0, the cutoff value was 0.34 (Sn. 68%, Sp. 75%) for APRI, while the cutoff value for FIB was 0.87 (Sn. 72%, Sp. 75%). The findings suggest that FIB-4 shows better diagnostic accuracy than APRI. Conclusion: This study provides optimal cutoff values for different groups of fibrosis patients for both serum markers. Also, the diagnostic accuracy of FIB-4 for predicting liver fibrosis was found to be superior to APRI in all disease stages.

External validation of LCR1-LCR2, a multivariable HCC risk calculator, in patients with chronic HCV

BACKGROUND & AIMS

The Liver Cancer Risk test algorithm (LCR1-LCR2) is a multianalyte blood test combining proteins involved in liver cell repair (apolipoprotein-A1 and haptoglobin), known hepatocellular carcinoma (HCC) risk factors (sex, age, and gamma-glutamyl transferase), a marker of fibrosis (alpha2-macroglobulin) and alpha-fetoprotein (AFP), a specific marker of HCC. The aim was to externally validate the LCR1-LCR2 in patients with chronic HCV (CHC) treated or not with antivirals.

METHODS

Pre-included patients were from the Hepather cohort, a multicentre prospective study in adult patients with CHC in France. LCR1-LCR2 was assessed retrospectively in patients with the test components and AFP, available at baseline. The co-primary study outcome was the negative predictive value (NPV) of LCR1-LCR2 for the occurrence of HCC at 5 years and for survival without HCC according to the predetermined LCR1-LCR2 cut-offs. The cut-offs were adjusted for risk covariables and for the response to HCV treatment, and were quantified using time-dependent proportional hazards models.

RESULTS

In total, 4,903 patients, 1,026 (21.9%) with baseline cirrhosis, were included in the study. Patients were followed for a median of 5.7 (IQR 4.2-11.3) years. A total of 3,788/4,903 (77.3%) patients had a sustained virological response. There were 137 cases of HCC at 5 years and 214 at the end of follow-up. HCC occurred at 5 years in 24/3,755 patients with low-risk LCR1-LCR2 compared with 113/1,148 patients with high-risk LCR1-LCR2. The NPV was 99.4% (95% CI 99.1-99.6). Similar findings (hazard ratio, 10.8; 95% CI, 8.1-14.3; p <0.001) were obtained after adjustment for exposure to antivirals, age, sex, geographical origin, HCV genotype 3, alcohol consumption, and type 2 diabetes mellitus.

CONCLUSIONS

The results showed that LCR1-LCR2 can be used to successfully identify patients with HCV at very low risk of HCC at 5 years.

LAY SUMMARY

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide and the fastest growing cause of cancer death in many countries. We constructed and internally validated a new multianalyte blood test to assess this Liver Cancer Risk (LCR1-LCR2). This study confirmed the performance of LCR1-LCR2 in patients with chronic HCV in the national French cohort Hepather, and its ability to identify patients at a very low risk of HCC at 5 years.

CLINICAL TRIALS REGISTRATION

The study is registered at ClinicalTrials.gov (NCT01953458).

Systematic review: Accuracy of the enhanced liver fibrosis test for diagnosing advanced liver fibrosis and cirrhosis

BACKGROUND AND AIMS

The rising incidence of chronic liver disease (CLD) has increased the need for early recognition. This systematic review assesses the diagnostic accuracy of the enhanced liver fibrosis (ELF) test in cases of advanced fibrosis and cirrhosis due to multiple etiologies in at-risk populations.

METHODS

Studies evaluating the ELF accuracy in identifying advanced fibrosis or cirrhosis, defined as METAVIR stage F ≥ 3 and F = 4 or equivalent, in patients with non-alcoholic fatty liver disease (NAFLD), alcohol liver disease (ALD), or viral hepatitis were included. Liver biopsy was used as the reference standard. Medline and Embase databases were searched. The QUADAS-2 tool was used as a framework to assess risk of bias and applicability. The area under the receiver operator curve (AUROC) was extracted as a summary measure of diagnostic accuracy.

RESULTS

Thirty-six studies were included: 11 hepatitis C, 4 hepatitis B, 9 NAFLD, 2 ALD, and 10 mixed. The ELF test showed good diagnostic performance in detecting advanced fibrosis in patients with viral hepatitis (AUROC 0.69 to 0.98) and excellent performance in NAFLD (AUROC 0.78 to 0.97) and ALD (AUROC from 0.92 to 0.94). There is also evidence of good diagnostic performance for detecting cirrhosis in patients with viral hepatitis (AUROC 0.63 to 0.99), good performance in NAFLD (AUROC 0.85 to 0.92), and excellent performance in patients with ALD (AUROC 0.93 to 0.94).

CONCLUSION

This systematic review supports the use of the ELF test across a range of CLD as a possible alternative to liver biopsy in selected cases.

Diagnostic value of serological biomarkers for detection of non-alcoholic fatty liver disease (NAFLD) and/or advanced liver fibrosis in people living with HIV

OBJECTIVES

We aimed to evaluate the accuracy of serological biomarkers for non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis (METAVIR-F3F4) in HIV mono-infected individuals.

METHODS

In all, 674 participants from the PROSPEC-HIV study (NCT02542020), who had blood sample tests and transient elastography (TE) performed on the same day, were eligible. Exclusion criteria were viral hepatitis co-infection (n = 90), abusive alcohol intake (n = 61), missing data (n = 47) or unreliable TE (n = 39). NAFLD was defined by controlled attenuation parameter ≥ 248 dB/m and advanced fibrosis by liver stiffness measurement ≥ 8.7 kPa with M probe or ≥ 7.2 kPa with XL probe. Biomarkers for NAFLD [Steato-ELSA, Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI), NAFLD-Liver Fat Score (NAFLD-LFS)] and fibrosis [Fibrosis-4 score (FIB-4), Aspartate-to-Platelet Ratio Index (APRI) and NAFLD Fibrosis Score (NFS)] were calculated.

RESULTS

A total of 437 patients [57% female, age = 44 (interquartile range: 35-52) years, body mass index (BMI) = 26.1 (23.4-29.3) kg/m² , CD4 = 660 (427-901) cells/μL] were included. The prevalence [95% confidence interval (CI)] of NAFLD and advanced fibrosis were 38.2% (33.8-42.9) and 10.5% (8.0-13.8), respectively. The areas (95% CI) under the receiver operator curve (AUROCs) for diagnosis of NAFLD were 0.854 (0.818-0.889), 0.840 (0.804-0.877), 0.805 (0.762-0.847) and 0.793 (0.750-0.836) for Steato-ELSA, FLI, HSI and NAFLD-LFS (P < 0.001), respectively. All tests yielded satisfactory sensitivities, specificities and negative predictive values (NPVs). The AUROCs (95% CI) for diagnosis of advanced fibrosis were 0.736 (0.659-0.814), 0.700 (0.614-0.7851) and 0.795 (0.726-0.864) for FIB-4, APRI and NFS (P = 0.077), respectively. These tests yielded high specificities and negative predictive values (NPVs) > 90%.

CONCLUSION

Biomarkers for NAFLD had a good accuracy and those for fibrosis had high specificities and NPVs. These tests should be integrated to HIV care to detect NAFLD and to exclude advanced liver fibrosis.

Dynamics of APRI and FIB-4 in HCV cirrhotic patients who achieved SVR after DAA therapy

There are limited data available on the regression of fibrosis in hepatitis C virus (HCV) patients who have achieved sustained virologic response (SVR) after interferon-free treatments. Moreover, a perfect method for assessing liver fibrosis and its dynamics has not been established yet. The main objective of this study was to evaluate the dynamics of aspartate aminotransferase to platelet ratio index (APRI) and Fibrosis-4 (FIB-4) scores in patients with HCV who registered SVR. We performed ROC curve analysis to evaluate the diagnostic performance of APRI and FIB-4 scores in determining the presence of cirrhosis in comparison to FibroTest. In total 251 patients were enrolled: 164 cirrhotic and 83 non-cirrhotic patients, and they were evaluated at baseline, at 6 and at 12 months post-end of treatment (EOT). In the cirrhotic group, at baseline, there was a weak but statistically significant correlation between APRI and FibroTest (τ=0.173, P=0.001), as well as between FIB-4 and FibroTest (τ=0.265, P<0.001). At the 6-month follow-up, APRI no longer correlated with FibroTest (τ=0.144, P=0.057), while FIB-4 was correlated (τ=0.256, P=0.001). The same pattern was shown at 12 months post-EOT. Between baseline and the 6-month evaluation, there was a significant decrease in APRI (P<0.001) and FIB-4 (P<0.001) scores, but for the next follow-up period, there was no reduction. In the non-cirrhotic group, APRI and FIB-4 did not correlate with the FibroTest value at any of the evaluation times. There was a significant difference between baseline and the 6-month visit for APRI (P=0.01) and for FIB-4 (P=0.014). The areas under the receiver operating characteristics curve (AUROCs) for the presence of cirrhosis compared with FibroTest for APRI and FIB-4 were 0.682 [95% confidence interval (CI), 0.613-0.752] and 0.693 (95% CI 0.625-0.76). Both APRI and FIB-4 prove to be easy, quick and inexpensive tools for screening HCV cirrhosis, with moderate diagnostic accuracy and FIB-4 can be useful for monitoring patients post-EOT.

The ALBI Grade is a Good Predictive Model for Very Late Recurrence in Patients with Hepatocellular Carcinoma Undergoing Primary Resection

BACKGROUND

Hepatocellular carcinoma (HCC) patients still have risk for very late recurrence after curative resection. This study assesses prognostic factors in HCC patients with recurrence-free survival (RFS) for 5 years after primary resection.

METHODS

We enrolled 383 HCC patients who received primary tumor resection and achieved more than 5 years without recurrence after resection between January 2001 and April 2013. Predictive factors, including albumin-bilirubin (ALBI) grade, for RFS and overall survival (OS) were analyzed.

RESULTS

After a median follow-up of 103 months, 57 patients (14.9%) had recurrent HCC, and 14 (3.7%) died. Independent predictors for HCC recurrence were male sex (p = 0.035), pre-operative liver cirrhosis (LC) (p = 0.025), serum creatinine  > 1.5 mg/dL (p = 0.045), post-operative 5th-year alpha-fetoprotein (AFP) > 15 ng/ml (p < 0.001), LC (p = 0.004), and ALBI grades 2 and 3 (p < 0.001). I ndependent risk factors for poor survival were age >70 years (p = 0.002), post-operative 5th-year AFP > 15 ng/ml (p = 0.003), and ALBI grades 2 and 3 (p = 0.002). Patients whose deteriorated ALBI grades 5 years after resection had adverse RFS outcomes compared to those with constant (p = 0.056) and improved ALBI grades (p = 0.008). In subgroup analysis, patients with post-operative 5th-year ALBI grades 2 and 3 had significantly poorer RFS and OS (both p < 0.001) than those with grade 1 among patients with low post-operative 5th-year AFP (<15 ng/mL).

CONCLUSION

In HCC patients without recurrence for 5 years after curative resection, post-operative 5th-year ALBI grade is useful for predicting outcomes, even with low AFP during follow-up.

Early Multiplexed Detection of Cirrhosis using Giant Magnetoresistive Biosensors with Protein Biomarkers

Liver cirrhosis is one of the leading causes of death in adults worldwide. It is highly prevalent in developing countries and is growing in prevalence in developed countries mostly because of chronic liver diseases, such as chronic hepatitis B and C and alcoholic and nonalcoholic fatty liver disease. However, the prevalence of cirrhosis may be highly underestimated because early stages are asymptomatic and current early detection methods are inadequate. Here, we evaluate the potential of a set of novel cirrhotic protein biomarkers, including soluble intercellular adhesion molecule-1 and mac-2 binding protein glycosylation isomer, for early detection of cirrhosis in a multiplexed assay using our giant magnetoresistive (GMR) sensor arrays. We evaluated the diagnostic performance of the biomarkers, individually and in combination, using multivariate logistic regression and random forest in a blinded proof-of-concept retrospective case-controlled study. The biomarkers in combination exhibited high diagnostic performance in both logistic regression and random forest models, with an area under the curve of 0.98 (0.94-1.00). In addition, the combination of biomarkers resulted in a high sensitivity of 0.97 (0.95-1.00) and a high specificity of 1.00. We showed that the diagnostic performance of our novel set of cirrhotic protein biomarkers on our multiplexed GMR sensor arrays is higher than the performance of currently used clinical biomarkers and factors (i.e., age, sex, alanine aminotransferase, aspartate aminotransferase, etc.). With this combination of novel biomarkers and GMR technology, we could potentially boost the diagnostic power of early cirrhosis detection.

Input of serum haptoglobin fucosylation profile in the diagnosis of hepatocellular carcinoma in patients with non-cirrhotic liver disease

BACKGROUND

Haptoglobin bifucosylated tetra-antennary glycan have been identified in patients with early stage hepatocellular carcinoma, but its specificity according to the presence or not of cirrhosis has never been assessed. The aims of this study were to determine if haptoglobin bifucosylated tetra-antennary glycan (1) could be a marker of HCC in patients without cirrhosis; (2) could increase the performance of standard alpha-fetoprotein (AFP) or recent blood tests for HCC detection, i.e., lectin-reactive alpha-fetoprotein (AFP-L3), des-gamma-carboxy prothrombin (DCP) and Liver-Cancer-Risk-test (LCR1-test).

METHODS

We retrospectively selected patients, 102 with HCC (21 without cirrhosis), matched by stages with 140 controls without HCC (81 without cirrhosis). Haptoglobin fucosylation was assessed by MALDI-TOF. LCR-glycan algorithm was constructed combining components of the LCR-1 test (haptoglobin, gammaglutamyl-transpeptidase, apolipoproteinA1, alpha-2-macroglobulin) with AFP, AFP-L3, DCP and haptoglobin bifucosylated tetra-antennary glycan.

RESULTS

In 102 patients without cirrhosis (21 HCC and 81 controls), the intention-to-diagnose analyses showed that haptoglobin bifucosylated tetra-antennary glycan alone had a sensitivity of 71% (15/21;95%CI 50-86), significantly better (P=0.02) than standard AFP (43%;9/21;95%CI 24-63), and a specificity of 96% (78/81;95% 90-99). The sensitivity of LCR-glycan, in patients without cirrhosis, was 86% (18/21; 95%CI 63-95) significantly better (P=0.001) than standard AFP (43%; 9/21; 95%CI 24-63), with an AUROC of 0.943 (95%CI 0.806-0.98) compared to 0.811 (95%CI 0.630-0.908) for AFP (P=0.06).

CONCLUSION

Haptoglobin bifucosylated tetra-antennary glycan is associated with the presence of HCC in patients with chronic liver disease including those without cirrhosis. Its combination with existing HCC biomarkers could improve the performance of standard AFP for HCC detection.

Investigation of Thrombosis Volume, Anticoagulants, and Recurrence Factors in Portal Vein Thrombosis with Cirrhosis

This retrospective study investigated factors influencing the portal vein thrombosis (PVT) volume and recurrence in 52 cirrhosis patients with PVT from November 2008 to September 2018. All patients were treated with danaparoid sodium with or without additional antithrombin III. Blood platelet counts significantly correlated with the PVT volume (r² = 0.17; P < 0.01). Computed tomography confirmed recurrence as PVT aggravation was reported in 43 patients, with ≥50% PVT volume reduction following anticoagulation therapy. In 43 patients, recurrence significantly correlated with the pretreatment PVT volume (P = 0.019). Factors influencing recurrence included a Child-Pugh score >8 (P = 0.049) and fibrosis index ≤7.0 based on four factors (FIB-4) (P = 0.048). Moreover, the relationship between recurrence and correlating factors showed that 15 patients who received warfarin experienced recurrence more often when Child-Pugh scores were >8 (P = 0.023), regardless of maintenance treatment. For patients who did not receive warfarin, a PVT volume ≥3.0 mL significantly influenced recurrence (P = 0.039). Therefore, the platelet count influences the PVT volume. The pretreatment PVT volume correlated with recurrence after anticoagulation therapy. According to the Kaplan-Meier curve, risk factors for PVT recurrence after anticoagulation therapy included Child-Pugh scores >8 and FIB-4 ≤7.0. Therefore, the FIB-4 is a unique factor that shows trends opposing other liver function markers.

Performance of liver biomarkers, in patients at risk of nonalcoholic steato-hepatitis, according to presence of type-2 diabetes

OBJECTIVE

There is a controversy about the performance of blood tests for the diagnostic of metabolic liver disease in patients with type-2-diabetes in comparison with patients without type-2-diabetes. These indirect comparisons assumed that the gold-standard is binary, whereas fibrosis stages, steatosis and nonalcoholic-steato-hepatitis (NASH) grades use an ordinal scale. The primary aim was to compare the diagnostic performances of FibroTest in type-2-diabetes vs. controls matched on gender, age, fibrosis stages and obesity, and taking into account the spectrum effect by Obuchowski measure.

METHODS

Data were retrospectively compared among patients prospectively included, with simultaneous biopsy and blindly assessed FibroTest, SteatoTest-2 and NashTest-2. The secondary aim was to construct an index (SpectrumF3F4-Index) to predict an adjusted-area under the receiver operating curve (AUROC) for F3F4 diagnosis from the prevalences of fibrosis stages, permitting to reduce the spectrum effect when performances of FibroTest, transient elastography and magnetic resonance elastography are indirectly compared.

RESULTS

In 505 patients at risk of NASH, the Obuchowski measures [95% confidence interval (CI)] of FibroTest, SteatoTest-2 and NashTest-2 were all equivalent in 136 type-2-diabetes cases vs. 369 matched controls: 0.871 (0.837-0.905), vs. 0.880 (0.879-0.881), 0.835 (0.797-0.873) vs. 0.806 (0.780-0.832) and 0.829 (0.793-0.865) vs. 0.855 (0.829-0.869), respectively. Standard-AUROCs (95% CI) were 0.932 (0.898-0.965), 0.872 (0.837-0.907) and 0.834 (0.699-0.969) and reduced after adjustment by SpectrumF3F4-Index to 0.794 (0.749-0.838), 0.767 (0.750-0.783) and 0.773 (0.725-0.822) for transient, magnetic resonance elastography and FibroTest, respectively.

CONCLUSIONS

When compared by Obuchowski measures, the performances of tests were not different in patients with T2-diabetes vs. patients without T2-diabetes. When individual data are not available, adjusted-AUROCs reduced the spectrum effect.

Review of Serum Biomarkers and Models Derived from Them in HBV-Related Liver Diseases

A series of predictive scoring systems is available for stratifying the severity of conditions and assessing the prognosis in patients with HBV-related liver diseases. We show nine of the most popular serum biomarkers and their models (i.e., serum cystatin C, homocysteine, C-reactive protein, C-reactive protein to albumin ratio, aspartate aminotransferase to platelet ratio index, fibrosis index based on four factors, gamma-glutamyl transpeptidase to platelet ratio, albumin-bilirubin score, and gamma-glutamyl transpeptidase to albumin ratio) that have gained great interest from clinicians. Compared with traditional scoring systems, these serum biomarkers and their models are easily acquired, simple, and relatively inexpensive. In the present review, we summarize the latest studies focused on these serum biomarkers and their models as diagnostic and prognostic indexes in HBV-related liver diseases.

Performance of Non-invasive Blood Parameters for Ruling Out Significant Liver Fibrosis in Patients with Chronic Hepatitis B

Background and Aims: Evaluation of significant liver fibrosis is important for treatment decision and treatment response evaluation in patients with chronic hepatitis B. Since liver biopsy is invasive and transient elastography (TE) has limited availability, various non-invasive blood parameters need evaluation for their capabilities for detection of significant fibrosis. Methods: In this retrospective study, records of patients who had undergone liver biopsy for treatment-naïve chronic hepatitis B were evaluated to obtain various non-invasive blood parameters (aspartate aminotransferase-to-platelet ratio index [referred to as APRI], Fibrosis-4 score [referred to as FIB-4], gamma-glutamyl transpeptidase-to-platelet ratio [referred to as GPR], and gamma-glutamyl transpeptidase-to-albumin ratio [referred to as GAR]), in addition to TE, to assess significant liver fibrosis and compare these to fibrosis stage in liver biopsy. Results: A total of 113 patients were included in the study (median age 33 [interquartile range: 11-82 years], 74% males). Most (75%) patients were HBeAg-negative. The liver biopsy revealed significant fibrosis (Ishak ≥3) in 13% of the patients and nil or mild fibrosis (Ishak <3) in 87% of the patients. TE findings were available for 85 patients, APRI and FIB-4 for 95 patients, GPR for 79 patients, and GAR for 78 patients. The median values of all the parameters were significantly higher in patients with significant fibrosis, as compared to patients with non-significant fibrosis, and all the blood parameters as well as TE were able to identify patients with significant fibrosis significantly well (p<0.05). All non-invasive parameters had low positive predictive value but negative predictive value above 92%. Compared to TE, all the non-invasive blood parameters had similar area under the curve for detecting significant fibrosis, with excellent negative predictive value (≥93%). Conclusions: Non-invasive blood parameters (APRI, FIB-4, GPR, and GAR) with negative predictive values above 93% are excellent parameters for ruling-out significant fibrosis in patients with chronic hepatitis B. These can be used at bedside in place of TE.

Non-invasive liver fibrosis scores are strongly associated with liver cancer mortality in general population without liver disease

BACKGROUND & AIMS

In a general population without known liver disease, we tested whether: (a) increased liver fibrosis scores (FIB-4 and APRI) are associated with liver cancer mortality and (b) the probability that a person with a higher score died of liver cancer.

METHODS

In a retrospective occupational cohort who underwent annual/biennial health examinations (between 2002 and 2015), subjects were excluded with known chronic liver disease. Based on their baseline FIB-4 and APRI scores, subjects were categorised in low-/intermediate-/high-risk groups for advanced liver fibrosis. Using Cox proportional hazards regression analyses adjusted hazard ratios (aHR) were estimated for liver cancer mortality, with the low-risk FIB-4/APRI group as the reference. Harrell's C statistics were also calculated.

RESULTS

In 200 479 participants, mean (SD) age was 36.4 (7.7) years. Median follow-up was 4.1 years (IQR 2.10-8.03) with 80 liver cancer deaths. High baseline FIB-4 or APRI scores occurred in 0.25% and 0.09% of subjects respectively. A high FIB-4 or APRI score was associated with a markedly increased risk of liver cancer mortality (aHRs 629.10 [95% CI 228.74-1730.20] and 80.42 [95% CI 34.37-188.18]) respectively. C statistics were FIB-4 = 0.841 (95% CI 0.735-0.946) and APRI = 0.933 (95% CI 0.864-0.999).

CONCLUSIONS

In a general population without known liver disease, high FIB-4 or high APRI (in keeping with a high probability of advanced fibrosis) occurred in 0.25% (FIB-4) and 0.09% (APRI) of subjects. Both scores were associated with a markedly increased risk of liver cancer mortality and FIB-4 and APRI models both strongly predicted liver cancer mortality.

Fibro-indices versus liver stiffness for prediction of significant fibrosis in hepatitis B virus-infected Egyptian patients; a single-center experience

Background: Liver fibrosis assessment is a key factor for disease management in hepatitis B virus (HBV). Several serum biomarkers have been introduced for noninvasive fibrosis assessment. This study aims to evaluate the validity of simple noninvasive indices, namely Fibrosis-4 score (FIB4), aspartate aminotransferase (AST) to Platelet Ratio Index (APRI), Goteborg University Cirrhosis Index (GUCI), and fibrosis index in evaluation of liver fibrosis in chronic HBV.Methods: 226 patients with chronic HBV genotype D were included. FIB4, APRI, GUCI, and fibrosis index were performed. Receiver operating characteristic (ROC) curves were used to predict ≥F2 fibrosis.Results: The mean age of patients was 39.00 years and 72.27% of patients were treatment naïve. Patients with ≥F2 hepatic fibrosis had significantly higher FIB-4 (1.58 ± 1.46 vs. 1.15 ± 1.09), APRI (0.68 ± 0.71 vs. 0.43 ± 0.37), GUCI score (0.75 ± 0.94 vs. 0.42 ± 0.29) and Fibrosis index (2.18 ± 0.84 vs. 1.84 ± 0.69). All studied indices were able to diagnose ≥F2 fibrosis. APRI had the highest area under the ROC (AUROC) of 0.67. Predictivity of all indices was higher in on-treatment vs naive patients.Conclusion: FIB4, APRI, and GUCI scores are acceptable, noninvasive, and cheap simple indices that can be helpful on treatment follow-up of fibrosis regression in the setting of low socioeconomic conditions compared to the relatively expensive fibroscan modality.

Using AST-platelet ratio index and fibrosis 4 index for detecting chronic hepatitis C in a large-scale community screening

Background

Aspartate transaminase-platelet ratio index (APRI) and fibrosis 4 (FIB-4) are two non-invasive indexes to predict liver fibrosis in liver disease. This study was to use APRI and FIB-4 to detect chronic virus hepatitis in community screenings.

Methods

From 2004 to 2013, a series of community-based health screenings for residents aged 40 and older were held in Tainan city. APRI and FIB-4 of each participant were calculated and their association further analyzed with hepatitis status.

Results

We enrolled 180359 participants including 18726 (10.4%) hepatitis B virus (HBV), 13428 (7.4%) hepatitis C virus (HCV), 1337 (0.7%) HBV plus HCV and 146868 (81.5%) Non-HBV Non-HCV. The prevalence of chronic HCV increased with the elevation of APRI cut-offs or FIB-4 cut-offs (13.9%, 28.1%, 38.8%, 45.2%, to 49.9% in APRI≥0.3, 0.5, 0.7, 0.9,1.1, p<0.001 for the linear trend; or 15.8%, 26.4%, 34.4% to 39.7% in FIB-4≥1.75, 2.75, 3.5, 4.25, p<0.001). At the township level, APRI≥ 0.7 and FIB-4≥ 3.5 were highly correlated with HCV infection (r = 0.95, p<0.001 in APRI and r = 0.809, p<0.001 in FIB-4) and hepatocellular carcinoma (HCC) development (r = 0.894, p<0.001 in APRI and r = 0.804, p<0.001 in FIB-4), but not correlated with HBV infection.

Conclusions

Community screenings derived APRI or FIB-4 can identify patient subsets with increased of underlying HCV infection and risk of incident HCC.

Tenofovir is a more suitable treatment than entecavir for chronic hepatitis B patients carrying naturally occurring rtM204I mutations

BACKGROUND

Hepatitis B virus (HBV) DNA polymerase mutations usually occur to long term use of nucleos(t)ide analogues (NAs), but they can occur spontaneously in treatment-naïve chronic hepatitis B (CHB) patients. The naturally occurring HBV DNA polymerase mutations might complicate antiviral therapy with NAs, leading to the generation of drug-resistant viral mutants and disease progression. The most common substitutions are known to be YMDD-motif mutations, but their prevalence and the influence on antiviral therapy is unclear.

AIM

To investigate prevalence of the naturally occurring rtM204I mutations in treatment-naïve CHB genotype C2 patients and their influence on antiviral therapy.

METHODS

A total of 410 treatment-naïve CHB patients infected with HBV genotype C2 strains were enrolled in this retrospective study. Among the 410 patients, 232 were treated with NAs for at least 12 mo. Significant fibrosis was defined as fibrosis-4 index > 3.25 or aspartate aminotransferase to platelet ratio index > 1.5. Complete viral response (CVR) during NAs was defined as undetectable serum HBV DNA (< 24 IU/mL). The rtM204I variants were analyzed by a newly developed locked nucleotide probe (LNA probe) based real-time PCR (LNA-RT-PCR) method.

RESULTS

The LNA-RT-PCR could discriminate rtM204I mutant-type (17 patients, 4.2%) from rtM204 wild-type (386 patients, 95.8%) in 403 of 410 patients (98.3% sensitivity). Multivariate analysis showed that naturally occurring rtM204I variants were more frequently detected in patients with significant fibrosis [odd-ratio (OR) 3.397, 95% confidence-interval (CI) 1.119-10.319, P = 0.031]. Of 232 patients receiving NAs, multivariate analysis revealed that achievement of CVR was reversely associated with naturally occurring rtM204I variants prior to NAs treatment (OR 0.014, 95%CI 0.002-0.096, P < 0.001). Almost patients receiving tenofovir achieved CVR at 12 mo of tenofovir, irrespective of pre-existence of naturally occurring rtM204I mutations (CVR rates: patients with rtM204I, 100%; patients without rtM204I, 96.6%), whereas, pre-existence of naturally-occurring rtM204I-mutations prior to NAs significantly affects CVR rates in patients receiving entecavir (at 12 mo: Patients with rtM204I, 16.7%; patients without rtM204I, 95.6%, P < 0.001).

CONCLUSION

The newly developed LNA-RT-PCR method could detect naturally occurring rtM204I mutations with high-sensitivity. Theses mutations were more frequent in patients with liver fibrosis. Tenofovir is a more suitable treatment than entecavir for CHB patients carrying the naturally occurring rtM204I mutations.

Significant Correlation Between Grip Strength and m2bpgi in Patients with Chronic Liver Diseases

: We sought to compare the impact upon grip strength (GS) between the Mac-2 binding protein glycosylation isomer (M2BPGi) and the Fibrosis-4 (FIB4) index in chronic liver disease (CLD) patients (n = 376: 171 males and 205 females, and 137 liver cirrhosis (LC) cases (36.4%)). Factors linked to the low GS (<26 kg in male and <18 kg in female) were also investigated using univariate and multivariate analyses. The median GS in males was 35.5 kg, while that in females was 21.1 kg. The median M2BPGi was 1.11 cutoff index, whereas the median FIB4 index was 2.069. In both male (P < 0.0001) and female (P = 0.0001), GS in LC patients was significantly lower than that in non-LC patients. In males, M2BPGi (r = -0.4611, P < 0.0001) and the FIB4 index (r = -0.4556, P < 0.0001) significantly correlated with GS. Similarly, in females, M2BPGi (r = -0.33326, P < 0.0001) and our FIB4 index (r = -0.26388, P = 0.0001) also significantly correlated with GS. In the multivariate analyses of factors linked to the low GS, independent factors were: M2BPGi (P = 0.0003) and skeletal muscle index (P = 0.0007) in males, and age (P < 0.0001) and serum albumin level (P = 0.0484) in females. In conclusion, liver fibrosis markers were well-correlated with GS in CLD patients. In particular, M2BPGi can be helpful for predicting the low GS in male patients.

Quantification of Hemodynamic Changes in Chronic Liver Disease: Correlation of Perfusion-CT Data with Histopathologic Staging of Fibrosis

RATIONALE AND OBJECTIVES

To noninvasively estimate the severity of liver fibrosis using perfusion-CT (PCT)-based quantification of dual liver blood supply prior to liver transplantation or liver resections and to correlate results with histological grading of fibrosis stages and AST-platelet ratio index.

MATERIALS AND METHODS

Institutional review board approved this retrospective study. We analysed 41 consecutive patients (19 classified as Child-Pugh A, 17 as Child-Pugh B, and 5 as Child-Pugh C; MELD score ranged from 7 to 28) who underwent PCT prior to liver transplantation/liver resections between 2013 and 2016. The examination protocol included a scan time of 40 s, 80 kV, 100/120 mAs. Arterial liver perfusion, portal-venous perfusion and hepatic perfusion index (HPI) were registered in liver parenchyma by three readers. Fibrosis was histological graded according to Ishak scoring system as liver fibrosis (F3, n = 10), incomplete liver cirrhosis (F5, n = 5), and complete liver cirrhosis (F6, n = 26).

RESULTS

Portal-venous perfusion was significantly higher in liver fibrosis (F3 69.5±23.7 ml/100 ml/min) compared to incomplete liver cirrhosis (F5, 52.9±25.7 ml/100 ml/min) and complete liver cirrhosis (F6, 46.4±24.8 ml/100 ml/min (range 6.3-112.0 ml/100 ml/min; F = 15, p < 0.0001). HPI showed the same group differences (F = 20, p < 0.0001; HPI F3: 19.1±10.7%, HPI F5: 38.5±24.3%, HPI F6: 43.4±25.8%). Group comparisons were not significant for arterial liver perfusion (F = 3, p = 0.15). PCT parameters as well as histological fibrosis grading did neither correlate with laboratory findings including AST-platelet ratio index and MELD-Score, nor with Child-Pugh-Score.

CONCLUSION

Quantitative data from perfusion-CT can be used to differentiate between liver fibrosis (F3) and liver cirrhosis (F5/F6).

Liver fibrosis staging with combination of APRI and FIB-4 scoring systems in chronic hepatitis C as an alternative to transient elastography

BACKGROUND

Liver disease severity must be determined before treatment of chronic hepatitis C (CHC). We evaluated the diagnostic performance of the APRI and FIB-4 scores compared to transient elastography liver stiffness (TE-LS) in detecting significant fibrosis (F3) or cirrhosis (F4).

METHODS

We retrospectively enrolled 575 patients with CHC who underwent TE-LS between May 2014 and September 2018: 365 (63.5%) male, mean age 51.54±12.4 years. APRI and FIB-4 scores were compared to TE-LS.

RESULTS

One hundred patients (17.5%) had TE-LS values between 9 and 11.9 kPa, and were classified as F3, while 265 (46%) were classified as F4 (TE-LS ≥12 kPa). APRI and FIB-4 scores predicted F4 patients adequately using cutoff values of 0.65 (sensitivity 85.5%, specificity 77%) and 1.63 (sensitivity 91%, specificity 77%), respectively. Cutoff values of 0.64 for APRI and 1.46 for FIB-4 predicted F3/F4 patients (sensitivity 72% and 81.5%; specificity 83% and 79%, respectively). The use of these cutoff values with APRI and FIB-4 in combination adequately predicted patients with significant fibrosis or cirrhosis (positive predictive value 91.5%), while cutoff values of 0.3 and 0.98, respectively, predicted F1/F2 patients with specificity 94.5% and sensitivity 26.5%, suggesting that in 58.5% of patients TE-LS could possibly be avoided.

CONCLUSIONS

The APRI/FIB-4 combination performed well in predicting significant fibrosis, while FIB-4 performed well in predicting cirrhosis. These noninvasive biochemical markers could be used as screening tools instead of LS measurement, which is not widely available. Further prospective validation studies are required to confirm this finding.

Liver fibrosis markers as assessed by ultrasound elastography and serum samples: A large comparative study in hepatitis virus B and C liver diseases

AIM

We aimed to compare the well-established liver fibrosis (LF) markers in Japanese patients with chronic hepatitis B (CHB, n = 331) and chronic hepatitis C (CHC, n = 886) and to discuss possible causes of differences in results between CHB patients and CHC patients.

METHODS

Virtual touch quantification (VTQ) in acoustic radiation force impulse, Fibrosis-4 (Fib-4) index, aspartate aminotransferase to platelet ratio index (APRI), and hyaluronic acid (HA) were compared between the two cohorts. As an additional investigation, total collagen proportional area (TCPA, %) was tested using liver pathological samples (n = 83).

RESULTS

Significant LF (F2 or greater) and advanced LF (F3 or greater) were identified in 153 (46.2%) and 76 (23.0%) patients in the CHB cohort and 579 (65.3%) and 396 (44.7%) patients in the CHC cohort. The median VTQ, Fib-4 index, APRI, and HA values in the CHB cohort were 1.20 m/s, 1.36, 0.44, and 25 ng/mL; those in the CHC cohort were 1.32 m/s, 2.60, 0.74, and 65.5 ng/mL (P-values, all <0.0001). Similar tendencies were noted by F stage-based stratification. The median TCPA in the CHB cohort and the CHC cohort were 8.5% and 12.7% (P < 0.0006). The TCPA values in the CHC cohort were higher than those in the CHB cohort regardless of LF stage.

CONCLUSION

Values of LF markers in CHB patients can differ from those in CHC patients even in the same LF stage. Difference in total amount of collagen fiber in CHB and CHC appears to be linked to the difference.

Effects of Hepatic Steatosis on Non-Invasive Liver Fibrosis Measurements Between Hepatitis B and Other Etiologies

Fibrosis-4 (FIB4), transient elastography (TE), and acoustic radiation force impulse (ARFI) are popular modalities to assess liver fibrosis. Their cutoff values for degrees of fibrosis vary between studies. The influence of hepatic steatosis on fibrosis measurements for different etiologies was evaluated. Data from a consecutive series of patients who received fibrosis measurement were included for the training group. An additional series with histology served as the validation group. A standardized protocol was performed for both TE and ARFI, mostly by a single technician. Patients with alcoholism, autoimmune disease, active inflammation, or who were receiving therapy were excluded. The training group included 215 patients and the validation group included 221. The correlation of liver stiffness between TE and ARFI was good (R2 linear = 0.798; p < 0.001). Different correlations between ARFI and TE were noted between high and low control attenuation parameter (CAP) values (cutoff: 290 dB/m), especially in the non-hepatitis B subgroups. Relatively lower FIB4 and TE values were seen in the high CAP versus low CAP in patients with histology-proven non-alcoholic fatty liver disease and chronic hepatitis C. FIB4 cutoff values were >25% lower among F2-F4 stages and the TE cutoff value for F4 was 8.5% lower in the high versus low CAP group. Such findings were not observed in chronic hepatitis B. Different fibrogenesis mechanisms between hepatitis B and non-B are discussed. We conclude that hepatic steatosis significantly impacts FIB4 and TE fibrosis measurements in non-hepatitis B-related liver diseases. Fibrosis grade should be interpreted with caution in severe steatosis.

Efficiency of acoustic radiation force impulse imaging for the staging of graft fibrosis after liver transplantation

AIM

Liver biopsy is the gold standard for assessing liver fibrosis (LF) after liver transplantation (LT), but its invasiveness limits its utility. This study aimed to evaluate the usefulness of liver stiffness measurement (LSM) using acoustic radiation force impulse (ARFI) imaging to assess LF after LT.

METHODS

Between September 2013 and January 2017, 278 patients who underwent liver biopsy after LT in Kyoto University Hospital (Kyoto, Japan) were prospectively enrolled. Liver stiffness measurement was carried out using ARFI imaging; its value was expressed as shear wave velocity (Vs) [m/s]. The LF was evaluated according to METAVIR score (F0-F4). The diagnostic performance of Vs for F2≤ and F3≤ was assessed and compared with that of laboratory tests using receiver operating characteristic (ROC) analysis.

RESULTS

The median Vs values increased according to the progression of LF (F0, 1.18 (0.78-1.92); F1, 1.35 (0.72-3.54); F2, 1.55 (1.05-3.37); F3, 1.84 (1.41-2.97)). The Vs had the highest area under the ROC curve (AUROC) for the prediction of both F2 ≤ and F3 ≤ fibrosis (F2, 0.77; and F3, 0.85). With the cut-off value of Vs >1.31, sensitivity, specificity, positive predictive value, and negative predictive value were 89.4%, 53.3%, 37.3%, and 94.2% in predicting F2≤, respectively. Shear wave velocity diagnosed LF better than any laboratory tests regardless of the type of primary disease.

CONCLUSIONS

Acoustic radiation force impulse helps to assess graft LF after LT. The high sensitivity suggested that ARFI might reduce the frequency of liver biopsies by detecting patients who are unlikely to have significant fibrosis after LT. (Unique trial no. UMIN R000028296.).

Comparison of non-invasive models for predicting liver damage in chronic hepatitis B patients

INTRODUCTION

Inexpensive blood tests have been well established as alternatives to liver biopsies to evaluate liver fibrosis in CHB patients. Here, we aim to compare their diagnostic accuracy in assessing liver fibrosis and necroinflammation.

PATIENTS AND METHODS

A retrospective study was performed to evaluate the predictive value of non-invasive models in chronic hepatitis B patients with liver fibrosis by the area under receiver operating characteristic curve (AUROC). The clinical data of 160 patients were collected from medical records.

RESULTS

Of the 160 consecutive treatment-naïve CHB patients, 29 (16%) had significant fibrosis and 34 (21%) had severe necroinflammation. The AUROC of the gamma-glutamyl transpeptidase to platelet ratio (GPR) (0.761, 95% CI 0.671-0.850) for predicting significant fibrosis was significantly higher than that of the aspartate transaminase-to-platelet ratio index (APRI) (0.680, 95% CI 0.585-0.774, p=0.034), but comparable with the fibrosis index based on four factors (Fib-4) (0.746, 95% CI 0.656-0.836, p=0.703), while for predicting severe necroinflammation, the performance of the GPR (AUROC=0.869, 95% CI 0.800-0.937) was better than the APRI (AUROC=0.816, 95% CI 0.740-0.892, p=0.085) and Fib-4 (0.792, 95% CI 0.711-0.873, p=0.023).

DISCUSSION

GPR is a satisfactory model to stage liver fibrosis and to grade necroinflammation activity, representing a convenient non-invasive alternative to liver biopsy in China.