ABSTRACT

Objectives:

To compare the efficacy of blood biochemical indicators with imaging techniques and biopsy data in detecting liver fibrosis in patients with chronic hepatitis B (CHB).

Materials and Methods:

One hundred fifty-three CHB patients followed without treatment in the Infectious Diseases Hepatitis Outpatient Clinic between 2021 and 2023 at Ege University Medical Faculty Hospital. The aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, fibrosis-4 (FIB-4) score, aspartate aminotransferase - platelet ratio index (APRI) score, and platelet (PLT) count were all calculated at the same time as the International Normalized Ratio (INR) level and FIB-4 score. Hepatobiliary system ultrasonography (USG) findings, demographic characteristics, hepatitis B virus (HBV)-DNA levels, ultrasoundbased elastographic imaging results, and liver biopsy results were assessed. With serum fibrosis markers, AST/ALT ratio, FIB-4 score, APRI score, INR level, PLT number and gender, age, HBV-DNA, liver damage levels via biopsy and ultrasound-based elastography and hepatobiliary system USG results and their relationship between each other were investigated.

Results:

Of the patients, 73 (47.7%) were male. The average age was 47.11±13.47 years. Being female, the AST/ALT ratio of more than 1 and being >40 years were found to be statistically significant. The rate of AST/ALT >1 was found to be significantly higher in patients with normal USG findings. The PLT count was found to be higher in the group with HBV-DNA >2000 IU/mL. The FIB-4 score was found to be higher only in males. There was no statistically significant difference between the genders in the APRI score; however, it was found to be higher in patients aged >40 years.

Conclusion:

To predict the progression to cirrhosis or hepatocellular carcinoma in CHB patients who do not match the treatment criteria per the Turkish CHB treatment reimbursement guideline, fibrosis risk was assessed using biochemical markers and radiological imaging techniques. However, it was determined that radiological imaging using serum markers is not a reliable way to predict fibrosis in its early stages.

Keywords:

Chronic HBV infection, liver fibrosis, non-invasive parameter, liver biopsy

Introduction

Detection of fibrosis in patients with chronic hepatitis B (CHB) has become an increasingly important issue in recent years in terms of evaluating the prognosis of the disease and quickly initiating antiviral treatment. The fact that hepatic fibrosis is not an irreversible process as it was accepted in the past, that the progression can be slowed and that it can be resolved to some extent with antiviral treatment has also accelerated the fibrosis diagnosis process (1).

The gold standard for staging hepatic fibrosis is the histopathological analysis of the liver biopsy specimen. Liver biopsy, however, has its own restrictions. The main drawbacks include the need for hospitalization, the difficulty of repeating it, the cost, the potential for deadly complications like hemorrhage and perforation, the capacity to sample just a limited portion of the liver, and the sampling variability and interobserver variability that come with these limitations (1,2,3). Due to these drawbacks, noninvasive techniques to detect hepatic fibrosis have been developed. Non-invasive fibrous testing can be used to determine the start of treatment in specific patient groups according to the 2017 viral hepatitis treatment guideline published by the European Association for the Study of the Liver [with hepatitis B virus (HBV)-DNA level >2000 IU\mL, alanine aminotransferase (ALT) levels normal and refusal to undergo biopsy] (4). These tests were evaluated in two separate groups as imaging and serum markers. In this study, early detection of fibrosis by serum markers and imaging methods and its statistical relationship with findings such as liver biopsy, age, gender, HBV-DNA level, and liver ultrasonography (USG) in CHB patients followed in our outpatient clinic and for whom treatment could not be initiated according to the Turkish CHB treatment reimbursement guideline were investigated.

Materials and Methods

The study included 153 CHB patients who did not receive treatment and were evaluated in the Infectious Diseases Hepatitis Outpatient Clinic at Ege University Hospital between January 2021 and March 2023. Demographic features, fibrosis-4 (FIB-4) (1.45-3.25) score, [aspartate aminotransferase - platelet ratio index (APRI) (0.5-2)] score, ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT >1) were calculated, International Normalized Ratio (INR), platelet (PLT) count, HBV-DNA levels [Cobas^® 6800 (Roche Molecular Diagnostics, Switzerland)], ultrasound-based elastographyimaging, hepatobiliary system USG findings and liver biopsy results were recorded retrospectively. HBV-DNA levels were classified as having HBV-DNA >2000 IU/mL at some point in life or having all measurements. Liver biopsy results were grouped as mild, moderate, and severe according to grade and stage values in the Ishak fibrosis staging. USG findings were divided into normal and abnormal (additional adiposity, increase in paraenchymal echogenicity, increase in portal vein diameter, etc.) ≤2000. The AST/ALT ratio, FIB-4 score, APRI score, INR number, and PLT number values; age (>40, sex ≤40), HBV-DNA (>2000 ve ≤2000), liver biopsy result (mild, moderate, severe), ultrasound-based elastography imaging result (F0, F1, F2), and hepatobiliary system USG result (normal, abnormal) were statistically compared with each other and analyzed.

The study was planned in accordance with the Helsinki Declaration decisions and the patient rights regulation, and the Turkish CHB treatment reimbursement guideline (HBV-DNA >2000 IU/mL or >10⁴ copy/mL and Ishak fibrosis score ≥2/6 or Histology Activity Index ≥6/18). Ethics committee approval was obtained from the Ege University Faculty of Medicine Clinical Research Ethics Committee (approval number: E-99166796-050.06.04-1197109, date: 27.03.2023).

Statistical Analysis

The SPSS statistical analysis program was used to evaluate the data. For numerical variables, first to fit the normal distribution Kolmogorow-Smirnov and Shaphiro-Wilk tests were performed. If the p (statistical significance) value was greater than 0.05 in both tests, it was accepted that the data had a normal distribution. T-test was used for the variables with a normal distribution, and the Mann-Whitney U test was used for those who did not. Statistically, p<0.05 was considered significant.

Results

When 153 CHB patients who were followed up between January 2021 and March 2023 and who did not receive treatment were analyzed 73 (47.7). Of the patients, 73 (47,7.3%) were male and the mean age was 47.11±13.48 years. The mean ALT, AST, PLT, and INR values of the patients were, respectively; 24.06±25.42 U/L, 20.81±12.24 U/L, 240.91±53.97 10³µL, and the INR value was 0.96±0.06. A serum marker AST/ALT ratio of more than 1 was found to be statistically significantly higher in females and individuals aged more than 40 years (p=0.00003, 0.0072, respectively). Contrary to expectations, the AST/ALT >1 rate was higher in patients with normal USG findings. (p=0.0146). When the PLT count was evaluated, there was no significant difference between the groups, but the platelet PLT was found to be higher in the group with HBV-DNA >2000 IU/mL (p=0.00154). The FIB-4 score was found to be higher only in males (p=0.0457), and no statistically significant difference was found in other parameters. There was no statistically significant difference between the genders in the APRI score, but it was found to be higher in patients aged more than 40 years (p=0.04). Contrary to expectations, the APRI score was found to be statistically significantly higher in patients with normal USG findings. The INR value was found to be high in patients aged 40 years (p=0.0055). Comparison data between groups are summarized in Table 1, 2.

Table 1

Table 2

Discussion

Liver biopsy is the gold standard method in the determination of fibrosis in CHB patients and is a necessary and mandatory practice in Turkey to initiate treatment for naive patients. In the last decade of hepatology, the determination of liver fibrosis by non-invasive diagnostic methods without biopsy and early initiation of treatment in certain groups by considering individual risk factors has been included in the guidelines and accepted internationally (4,5,6,7).

In this research, we did not encounter a patient in our chronic HBV patient group for whom we could not start treatment according to the Turkish CHB treatment reimbursement guideline, and we thought it necessary to start treatment with non-invasive serum fibrous markers and ultrasound-based elastography methods. This situation is mainly due to the analyzed patient group, we attribute ALT, AST, PLT, and INR values to the patients with mild disease according to their HBV-DNA mean. In addition, the young age and female gender predominance of the patient group were also effective in this result.

Williams and Hoofnagle (8) showed in a retrospective study that AST/ALT ≥1 is significant for cirrhosis in a population of patients with non-alcoholic liver disease. Reedy et al. (9), on the other hand, stated in their study that the AST/ALT ratio evaluated before the treatment of chronic HCV infection could not accurately predict the presence of cirrhosis and the need for liver biopsy continued. Although AST/ALT ratio more than 1 was found to be higher in the female gender and >40 age group in our study, it was unexpectedly found to be statistically higher in individuals with normal USG findings. The lack of a statistically significant relationship between biopsy and elastography results might be due to the insufficient number of the study group.

Low PLT count and especially recently prolonged INR have been mentioned in many publications as important markers of cirrhosis and advanced fibrosis (10,11). Gold standard liver biopsy and non-invasive serum fibrous markers were compared retrospectively in 464 patients who underwent surgical resection for hepatocellular cancer. Where ISHAK score and 10 different non-invasive fibrous markers were compared, no significant correlation was found between tests and biopsy scores (12). The fact that such a result was obtained even in the patient group with high fibrosis is supportive in terms of the accuracy of the results of our study, in which patients with mild fibrosis were predominant.

FIB-4 and APRI scoring systems have been routinely used in recent years to determine fibrosis. In this respect Shin et al. (13) showed that the APRI score is a reliable method for estimating fibrosis. Another study in patients with chronic HCV concluded that the APRI score was more reliable in predicting fibrosis in women than in men (14). Yilmaz et al. (15), in their study on 207 CHB, 108 CHC and 140 NAFLD patients, showed results that correlated with liver biopsy, with APRI score showing significant fibrosis in all three patient groups. In the study of Sayar et al. (16), the diagnostic performance of the FIB-4 index in determining cirrhosis was found to be good. Kaya et al. (17) found that the negative predictive value of FIB-4 index was high.

Wai et al. (18) compared the biopsy results with the APRI score in untreated patients with chronic HBV and demonstrated that the APRI score was successful in identifying patients with significant fibrosis and cirrhosis. In the study of Lin et al. (19), on the other hand, they found that APRI could identify fibrosis associated with CHB with moderate accuracy. At the latest, in a publication in which high patient data such as 69,106 were reviewed retrospectively, the diagnostic value of FIB-4 and APRI test results in determining fibrosis was found to be low. In this publication, it was reported that 86% and 67% of patients with fibrous F3-F4 scores, respectively, with FIB-4 and APRI scores were misdiagnosed as F1-F2 (20,21). Statistically significant in our study, in patients with APRI score >40 years; FIB-4 score was found to be higher in males; It was found to be compatible with some literature, but there are also studies reporting different results.

Imaging techniques, one of the noninvasive methods that detect fibrosis, have taken their place in the guides in terms of diagnosis (4). Studies have reported that fibroscan and serum biomarkers have similar performance in detecting fibrosis in hepatitis patients with significant fibrosis (22). Although the combination of fibroscan and serum biochemical markers is more effective than the combination of the two serum markers, its higher cost draws attention in studies (4,23,24). In our study, fibroscan and biopsy findings did not yield statistically significant results with non-invasive biochemical tests. We think that our patient group consisted of patients with m, and fibrosis and the comparison of fibroscan and biopsy results in a few patients is probably responsible for this situation.

In our study, the APRI score and AST/ALT ratio were found to be higher in individuals with normal USG findings, contrary to expectations. We think that the reason for this is that our patients are in the young age group with mild disease without advanced liver damage. Another problem is that USG evaluations were made at different times and by different radiologists. USG is the first preferred imaging method because it is inexpensive and easily accessible in detecting chronic liver damage (25). Demir et al. (26) investigated the value of ultrasound in the diagnosis of early cirrhosis by comparing the histopathological findings of patients with chronic viral hepatitis with ultrasound changes in the liver. In this study, it was determined that the most sensitive finding in the diagnosis of early cirrhosis was the irregularity of the liver parenchyma. In another study, it was reported that ultrasound had a diagnostic accuracy of 84-87% for the diagnosis of significant fibrosis, 89-91% for the diagnosis of severe fibrosis, and 92-93% for the diagnosis of liver cirrhosis (27).

Study Limitations

The limitations of our study are that we have biopsy and fibroscan results from a limited number of patients and that these results are not concurrent with serum fibrous markers.

Conclusion

We think that this study is an original study in terms of complicating the possibility of early treatment by comparing serum fibrous markers and imaging tests used to detect liver fibrosis with the factors of the patient.

The risk of fibrosis was assessed with noninvasive biochemical and radiological tests, and their superiority over liver biopsy was investigated in CHB patients who did not receive treatment because they did not meet the current treatment criteria in order to prevent progression to cirrhosis and hepatocellular cancer. We could not uncover any results in our study that supported our hypothesis that these technologies, which are affordable, simple, and accessible, can prevent both patients and doctors from an intrusive operation such as a biopsy. Our research has led us to believe that non-invasive fibrous indicators are not yet a viable substitute for liver biopsies, but they do have a negative predictive value when deciding whether to begin treatment.

Ethics

Ethics Committee Approval: Ethics committee approval was obtained from the Ege University Faculty of Medicine Clinical Research Ethics Committee (approval number: 2023-033623-3T/25, date: 16.02.2023).

Informed Consent: Retrospective study.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: N.Y., H.P., T.Y., Concept: N.Y., H.P., T.Y., Design: N.Y., H.P., T.Y., Data Collection or Processing: N.Y., A.K., G.Ş.İ., M.M.V., H.P., T.Y., Analysis or Interpretation: N.Y., A.K., H.P., T.Y., Literature Search: N.Y., H.P., T.Y., Writing: N.Y., H.P., T.Y.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declare no financial support.

References

Gilmore IT, Burroughs A, Murray-Lyon IM, Williams R, Jenkins D, Hopkins A. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London. Gut. 1995;36:437-441.

Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection. Am J Gastroenterol. 2002;97:2614-2618.

El-Zayadi AR, Badran HM, Saied A, Shawky S, Attia Mel-D, Zalata K. Evaluation of liver biopsy in Egyptian HBeAg-negative chronic hepatitis B patients at initial presentation: implications for therapy. Am J Gastroenterol. 2009;104:906-911.

European Association for Study of Liver; Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol. 2015;63:237-264.

Dhyani M, Anvari A, Samir AE. Ultrasound elastography: liver. Abdom Imaging. 2015;40:698-708.

Gheorghe G, Bungău S, Ceobanu G, Ilie M, Bacalbaşa N, Bratu OG, Vesa CM, Găman MA, Diaconu CC. The non-invasive assessment of hepatic fibrosis. J Formos Med Assoc. 2021;120:794-803.

Soresi M, Giannitrapani L, Cervello M, Licata A, Montalto G. Non invasive tools for the diagnosis of liver cirrhosis. World J Gastroenterol. 2014;20:18131-18150.

Williams AL, Hoofnagle JH. Ratio of serum aspartate to alanine aminotransferase in chronic hepatitis. Relationship to cirrhosis. Gastroenterology. 1988;95:734-739.

Reedy DW, Loo AT, Levine RA. AST/ALT ratio > or = 1 is not diagnostic of cirrhosis in patients with chronic hepatitis C. Dig Dis Sci. 1998;43:2156-2159.

Qamar AA, Grace ND, Groszmann RJ, Garcia-Tsao G, Bosch J, Burroughs AK, Ripoll C, Maurer R, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Makuch R, Rendon G; Portal Hypertension Collaborative Group. Incidence, prevalence, and clinical significance of abnormal hematologic indices in compensated cirrhosis. Clin Gastroenterol Hepatol. 2009;7:689-695.

Wang Y, Dong F, Sun S, Wang X, Zheng X, Huang Y, Li B, Gao Y, Qian Z, Liu F, Lu X, Liu J, Ren H, Zheng Y, Yan H, Deng G, Qiao L, Zhang Y, Gu W, Xiang X, Zhou Y, Xu B, Hou Y, Zhang Q, Xiong Y, Zou C, Chen J, Huang Z, Jiang X, Qi T, Luo S, Chen Y, Gao N, Liu C, Yuan W, Mei X, Li J, Li T, Zheng R, Zhou X, Zhang W, Li H, Meng Z. Increased INR Values Predict Accelerating Deterioration and High Short-Term Mortality Among Patients Hospitalized With Cirrhosis or Advanced Fibrosis. Front Med (Lausanne). 2021;8:762291.

Ho SY, Liu PH, Hsu CY, Hsia CY, Su CW, He YJ, Lee YH, Huang YH, Hou MC, Huo TI. Current noninvasive liver reserve models do not predict histological fibrosis severity in hepatocellular carcinoma Sci Rep. 2018;8:15074.

Shin WG, Park SH, Jang MK, Hahn TH, Kim JB, Lee MS, Kim DJ, Jun SY, Park CK. Aspartate aminotransferase to platelet ratio index (APRI) can predict liver fibrosis in chronic hepatitis B. Dig Liver Dis. 2008;40:267-274.

Shah AG, Lydecker A, Murray K, Tetri BN, Contos MJ, Sanyal AJ; Nash Clinical Research Network. Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2009;7:1104-1112.

Yilmaz Y, Yonal O, Kurt R, Bayrak M, Aktas B, Ozdogan O. Noninvasive assessment of liver fibrosis with the aspartate transaminase to platelet ratio index (APRI): Usefulness in patients with chronic liver disease: APRI in chronic liver disease. Hepat Mon. 2011;11:103-106.

Sayar S, Atalay R, Cakmak S, Ayrancı G, Kürbüz K, Kahraman R, Calışkan Z, Öztürk O, Demirdağ H, Adalı G, Özdil K, Doğanay HL. Diagnostic Performance of Non-invasive Fibrosis Indexes in Hepatitis B Related Fibrosis. Viral Hepat J. 2020;26:78-84 (Turkish).

Kaya O, Akçam FZ, Sönmez Y, Tığlı A, Çiriş M. Evaluation of Non-invasive Methods for Prediction of Fibrosis in Chronic Hepatitis B and C Infections. Viral Hepat J. 2009;14:91-97 (Turkish).

Wai CT, Greenson JK, Fontana RJ, Kalbfleisch JD, Marrero JA, Conjeevaram HS, Lok AS. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38:518-526.

Lin ZH, Xin YN, Dong QJ, Wang Q, Jiang XJ, Zhan SH, Sun Y, Xuan SY. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatology. 2011;53:726-736.

Hashem A, Awad A, Shousha H, Alakel W, Salama A, Awad T, Mabrouk M. Validation of a machine learning approach using FIB-4 and APRI scores assessed by the metavir scoring system: A cohort study. Arab J Gastroenterol. 2021;22:88-92.

Kesimal U, Öztürk Durmaz Ş. (2021). Comparison of non-invasive fibrosis scoring methods with liver biopsy in chronic hepatitis B patients. Akd Med J. 2021;7:283-288 (Turkish).

Castéra L, Vergniol J, Foucher J, Le Bail B, Chanteloup E, Haaser M, Darriet M, Couzigou P, De Lédinghen V. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology. 2005;128:343-350.

AASLD/IDSA HCV Guidance Panel. Hepatitis C guidance: AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus. Hepatology. 2015;62:932-954.

Köksal İ, Yılmaz G, Parlak M, Demirdal T, Kınıklı S, Candan M, Kaya A, Akhan S, Aydoğdu Ö, Turgut H, Gürbüz Y, Dağlı Ö, Gökal AA, Güner R, Kuruüzüm Z, Tarakçı H, Beslen N, Erdoğan S, Özdener F, Study Group TCHC. Diagnostic value of combined serum biomarkers for the evaluation of liver fibrosis in chronic hepatitis C infection: A multicenter, noninterventional, observational study. Turk J Gastroenterol. 2018;29:464-472.

Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet. 2014;383:1749-1761.

Demir A, Akarca US, Yılmaz F, Özütemiz Ö, Karasu Z, İlter T. The place of ultrasonography in the diagnosis of early-stage cirrhosis. Turk J Gastroenterol. 1999 (Turkish).

Clevert DA, Beyer G, Nieß H, Schlenker B. Ultrasound—New Techniques Are Extending the Applications. Dtsch Arztebl Int. 2023;120:41-47.

Can We Accurately Assess Fibrosis in Chronic Hepatitis B Virus Patients?