Chronic hepatitis B virus monoinfection at a university hospital in Zambia

Systematic review and individual-patient-data meta-analysis of non-invasive fibrosis markers for chronic hepatitis B in Africa

In sub-Saharan Africa, simple biomarkers of liver fibrosis are needed to scale-up hepatitis B treatment. We conducted an individual participant data meta-analysis of 3,548 chronic hepatitis B patients living in eight sub-Saharan African countries to assess the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index and two other fibrosis biomarkers using a Bayesian bivariate model. Transient elastography was used as a reference test with liver stiffness measurement thresholds at 7.9 and 12.2kPa indicating significant fibrosis and cirrhosis, respectively. At the World Health Organization-recommended cirrhosis threshold (>2.0), aspartate aminotransferase-to-platelet ratio index had sensitivity (95% credible interval) of only 16.5% (12.5-20.5). We identified an optimised aspartate aminotransferase-to-platelet ratio index rule-in threshold (>0.65) for liver stiffness measurement >12.2kPa with sensitivity and specificity of 56.2% (50.5-62.2) and 90.0% (89.0-91.0), and an optimised rule-out threshold (<0.36) with sensitivity and specificity of 80.6% (76.1-85.1) and 64.3% (62.8-65.8). Here we show that the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index threshold is inappropriately high in sub-Saharan Africa; improved rule-in and rule-out thresholds can optimise treatment recommendations in this setting.

Clinical treatment of chronic hepatitis B virus infection in indeterminate phase: Current status and future prospects

The natural history of chronic hepatitis B virus (HBV) infection is usually divided into four stages: Immune tolerant phase (IT), hepatitis B e antigen (HBeAg) positive chronic hepatitis B (CHB) (i.e., immune clearance phase), immune control (IC) phase, and HBeAg negative CHB (i.e., reactivation phase). Patients whose HBeAg, alanine aminotransferase (ALT), HBV DNA, and hepatic histopathology fall into an indeterminate phase are divided into the following four groups: (1) Indeterminate phase related to IT: HBV DNA < 10⁶ IU/mL or significant inflammation and fibrosis, while other indicators are in line with IT; (2) Indeterminate phase related to HBeAg positive CHB: HBV DNA < 2 × 10⁴ IU/mL or ALT 1-2 times the upper limit of normal (ULN), while the rest indicators are consistent with HBeAg positive CHB; (3) Indeterminate phase related to IC: HBV DNA > 2 × 10³ IU/mL or significant inflammation and fibrosis, while other indicators meet IC; and (4) Indeterminate phase related to HBeAg negative CHB: HBV DNA < 2 × 10³ IU/mL or ALT 1-2 ULN, while the remaining indicators are in accordance with HBeAg negative CHB. In China, it is estimated that about 70 million people have chronic HBV infection, of which about 20-30 million are CHB patients. The percentage of liver cirrhosis and hepatocellular carcinoma caused by HBV infection is 77% and 84%, respectively. Chronic HBV infection brings severe burden to people's life and health as well as the national health care system. Although existing guidelines recommend dynamic monitoring of serum ALT and HBV DNA levels and assessment of liver histology of indeterminate zone, whether to initiate antiviral therapy in these patients remains controversial. This review mainly introduces the clinical treatment status of CHB patients in IC and indeterminate phase related to IC, and the future prospects of antiviral treatment for these patients.

Prevalence of liver cirrhosis in individuals with hepatitis B virus infection in sub-Saharan Africa: Systematic review and meta-analysis

BACKGROUND & AIMS

Chronic hepatitis B virus (HBV) infection accounts for 30%-50% of cirrhosis related deaths in sub-Saharan Africa (SSA). Since HBV-related cirrhosis is an indication for immediate antiviral therapy and cancer surveillance, we aimed to estimate the prevalence of cirrhosis among treatment-naïve patients with chronic HBV infection in SSA.

METHODS

We performed a systematic review of published articles which evaluated liver fibrosis stage among treatment-naïve HBV-infected individuals who presented to care in SSA. Our primary outcome was the prevalence of cirrhosis in HBsAg-positive persons, which was estimated using random-effects meta-analysis. Risk factors for cirrhosis were explored using subgroup-analyses and multivariable meta-regression.

RESULTS

Of 2129 articles identified, 17 met our eligibility criteria. The studies described 22 cohorts from 13 countries, including 13 cohorts (3204 patients) with chronic HBV mono-infection and nine cohorts (688 patients) with HIV/HBV-coinfection. Liver fibrosis was assessed using transient elastography (10 cohorts), APRI score (11 cohorts), and Fibrotest (one cohort). The pooled prevalence of cirrhosis was 4.1% (95% confidence interval [CI] 2.6-6.4) among studies from primary care facilities or general population, compared to 12.7% (95% CI 8.6-18.3) in studies performed in referral or tertiary care facilities (adjusted odds ratio 0.29, 95% CI 0.15-0.56). We found no association between cirrhosis and age, gender, fibrosis test used or HIV-coinfection.

CONCLUSIONS

Depending on the setting, between 4% and 13% of HBV-infected individuals in SSA have cirrhosis and need immediate antiviral therapy. These estimates should be considered when planning HBV treatment strategies and resource allocation.