This study aimed to evaluate factors associated with significant liver histological changes. Liver biopsies from 157 CHB patients were retrospectively analyzed. Only ALB was significantly correlated with advanced liver necroinflammatory (
Globally, there are approximately 350–400 million people infected with chronic hepatitis B virus (CHB) [
Liver biopsy remains the investigation of choice for assessment of inflammation and fibrosis. Liver biopsy is recommended for certain patients with chronic HBV infection especially older patients, those with persistent HBV DNA levels above 2,000 IU/mL and ALT 1-2 × the upper limit of normal (ULN), according to the Asian Pacific Association for the Study of the Liver (APASL), the European Association for the Study of the Liver (EASL), and the American Association for the Study of Liver Diseases (AASLD) [
Entry criteria to the study included treatment-naïve patients with chronic HBV infection who had a liver biopsy between Oct 2009 and Dec 2012 at the Taizhou People’s Hospital, Jiangsu, China. Patients were recruited if they were positive for hepatitis B surface antigen (HBsAg) for at least 6 months, with an HBV DNA level of more than 500 copies/mL and a prothrombin time of less than 18 sec. We excluded patients (1) with viral coinfections, including HCV, HDV, and HIV infection, (2) with decompensated liver disease, (3) with metabolic or autoimmune liver disease, and (4) with a history of hepatotoxic drug ingestion and a high alcohol intake (20 grams per day for female, 30 grams per day for male). Written consent was obtained prior to liver biopsy.
Fasting serum samples were tested one day prior to liver biopsy for laboratory parameters by standard methods. Fifteen parameters including clinical, biochemical, and hematological variables were analyzed: age, gender, HBeAg status, HBV DNA level, PT (prothrombin time), ALB (albumin), GLOB (globulin), TB (total bilirubin), TP (total protein), ALT (alanine aminotransferase), AST (aspartate aminotransferase), ALP (alkaline phosphatase), GGT (glutamyl transferase), PLT (platelet count), and WBC (white blood cell). Hepatitis B serology including HBsAg/Ab, HBeAg/Ab, and HBcAb was detected by enzyme-linked immunosorbent assay (Fosun Pharmaceutical Co., Shanghai, China). HBV DNA level was determined with a lower limit of quantification of 500 copies/mL (about 100 IU/mL) by real-time polymerase chain reaction (PCR) (Fosun Pharmaceutical Co., Shanghai, China).
The main equipments used in this study included ABI Real-time PCR analyzer 7500 and BioTek Synergy2 Multi-Mode Microplate Reader, USA, HITACHI Biochemical analyzer 7600, and automatic blood analyzer Sysmex XT-2000i, Japan.
Ultrasonographic-guided liver biopsies were performed using 16 G disposable needles (TSK corporation, Japan). Histological grading of necroinflammation and staging of liver fibrosis were considered reliable when the liver specimen length was ≥15 mm or the portal tract number ≥10 [
The baseline data of patients were presented as the median. Statistical analysis was carried out with SPSS 13.5 software for windows (SPSS Inc., Chicago, IL, USA). Chi-square test was used for categorical variables, the Student
A total of 157 patients with all 15 clinical parameters available were enrolled into the study. There were 48 patients with inflammatory active grade A0-A1 and 109 at A2-A3 and 81 patients at liver fibrosis stage F0-F1 and 76 at F2–F4. The characteristics of all 157 patients are shown in Table
Characteristics of 157 patients included in the study.
Variables | Total | A0-A1 | A2-A3 | F0-F1 | F2–F4 |
---|---|---|---|---|---|
Number of patients | 157 | 48 | 109 | 81 | 76 |
Age (years) | 38 (14–68) | 36 (14–58) | 39 (18–68) | 36 (14–64) | 41 (25–68) |
Gender (male) | 136 (87%) | 40 (83%) | 96 (91%) | 68 (84%) | 68 (89%) |
HBeAg+ | 68 (43%) | 21 (44%) | 47 (43%) | 41 (51%) | 27 (36%) |
HBeAg− | 89 (57%) | 27 (56%) | 62 (57%) | 40 (49%) | 49 (64%) |
HBV DNA (log copies/mL) | 6 (2–9) | 5.5 (3–9) | 6 (2–9) | 6 (2–9) | 5.5 (2–8) |
PT (sec) | 13 (8.2–17.8) | 13 (8.2–16) | 13.1 (9.2–17.8) | 12.8 (8.2–16.7) | 13.7 (9.5–17.8) |
ALB (g/L) | 42.5 (30.1–53.9) | 43.3 (33.5–53.7) | 42 (30.1–53.9) | 43.3 (33.3–53.9) | 41.15 (30.1–48.9) |
GLOB (g/L) | 31.2 (21.9–48.2) | 30.5 (23.3–48.1) | 31.9 (21.9–48.2) | 30.2 (21.9–45.9) | 33.1 (23.9–48.2) |
TB (umol/L) | 16.2 (5.9–218) | 14.5 (6.1–84.7) | 16.3 (5.9–218) | 14.3 (5.9–218) | 18.1 (6.1–170.5) |
TP (g/L) | 74.1 (59.5–92.5) | 75.3 (64.4–92.5) | 74 (59.5–87.1) | 74 (60.6–92.5) | 74.6 (59.5–89.3) |
ALT (IU/L) | 69 (13–1387) | 64 (18–1387) | 72 (13–1215) | 62 (13–1387) | 71 (17–999) |
AST (IU/L) | 46 (14–723) | 44.5 (16–658) | 47 (14–723) | 40 (14–571) | 58 (17–723) |
ALP (IU/L) | 79 (35–323) | 73 (35–323) | 80 (41–258) | 74 (35–323) | 88 (42–258) |
GGT (IU/L) | 43 (7–476) | 38 (7–467) | 46 (11–402) | 30 (7–476) | 62 (15–402) |
PLT |
115 (19–314) | 122.5 (43–257) | 114 (19–314) | 132 (28–257) | 97 (19–314) |
WBC ( |
4.69 (1.96–7.77) | 4.68 (2.73–7.64) | 4.7 (1.96–7.77) | 5.11 (2.4–7.77) | 4.32 (1.96–7.64) |
Continuous variables are expressed as the median (range).
A total of 34 patients were aged ≦30, 57 aged 30–40, 45 aged 40–50, and 21 aged >50. There was no significant difference in necroinflammation grades among different age groups (
Distribution of liver necroinflammation and liver fibrosis (based on Metair Score) among different age groups in 157 patients with chronic HBV infection.
The presence of HBeAg and hepatitis B viral load decreased with age: 28 (82%) and 28 (82%) had HBV DNA ≧ 5log copies/mL and HBeAg+, respectively, among the 34 patients aged ≦30. Seven (33%) and 3 (14%) had HBV DNA ≧ 5log copies/mL and HBeAg+, respectively, among the 21 patients aged >50 (Figure
Characteristic of HBV DNA and HBeAg status among different age groups in 157 patients with chronic HBV infection.
A total of 31 patients (19.7%) had ALT levels within the normal range suggested by Prati et al. [
The distribution of liver necroinflammation and fibrosis in patients with normal and abnormal ALT.
Advanced necroinflammation was found in 39.8% of HBeAg+ patients and 55.1% of HBeAg− patients. Advanced fibrosis was found in 62.2% of HBeAg+ patients and in 69.7% of HBeAg− patients. There was no significant difference between HBeAg+ and HBeAg− groups in necroinflammation grades and fibrosis stages (
Distribution of liver necroinflammation and liver fibrosis (based on Metair Score) among HBeAg+ and HBeAg− groups.
Two levels of liver fibrosis (F0-F1 and F2–F4) and liver necroinflammation (A0-A1 and A2-A3) were analyzed in 157 patients with chronic HBV infection. Of the 15 variables, only ALB was significantly correlated with advanced liver necroinflammation (
Clinical parameters predictive of advanced liver necroinflammation and fibrosis.
|
Spearman’s correlation | Logistic regression | |||||||
---|---|---|---|---|---|---|---|---|---|
|
|
Correlation coefficient |
|
OR value |
|
95% CI for OR | |||
Lower | Upper | ||||||||
A2-A3 | ALB | 3.238 | 0.001 | −0.236 | 0.003 | 0.888 | 0.002 | 0.823 | 0.958 |
F2–F4 | Age | −3.075 | 0.002 | 0.245 | 0.002 | 2.113 | 0.002 | 1.330 | 3.356 |
ALB | 4.099 | <0.001 | −0.291 | <0.001 | 0.119 | 0.037 | 0.016 | 0.879 | |
GLOB | −3.282 | 0.001 | 0.249 | 0.002 | 0.136 | 0.049 | 0.019 | 0.988 | |
AST | −1.997 | 0.048 | 0.235 | 0.003 | 1.031 | 0.011 | 1.007 | 1.055 | |
PLT | 4.548 | <0.001 | −0.383 | <0.001 | 0.991 | 0.037 | 0.982 | 0.999 | |
PT | −3.355 | 0.001 | 0.256 | 0.001 | 1.641 | <0.001 | 1.252 | 2.151 |
The area under ROC curve (AUC) of ALB for significant necroinflammation in all patients was 0.614. The 95% confidence interval was 0.501 to 0.727. PLT was a good predictor for cirrhosis and its AUROC was 0.805. The AUC of the predictors for cirrhosis was shown in Table
The area under ROC curve (AUC) of the identified variables for cirrhosis in all patients.
AUC for cirrhosis | 95% confidence interval | ||
---|---|---|---|
Lower | Upper | ||
Age | 0.728 | 0.610 | 0.846 |
ALB | 0.721 | 0.600 | 0.841 |
GLOB | 0.760 | 0.645 | 0.875 |
AST | 0.681 | 0.554 | 0.808 |
PLT | 0.805 | 0.702 | 0.908 |
PT | 0.708 | 0.581 | 0.834 |
The development of noninvasive markers for liver fibrosis is an attractive option because of the associated risks of liver biopsy. Previous studies have shown inconsistent results and the optimal predictor for significant liver fibrosis is not known. This study investigated the association of various routinely available clinical parameters with liver histology.
Current guidelines for antiviral treatment of chronic HBV infection recommend therapy when ALT levels are more than twice the upper limit of normal; however, previous studies have not demonstrated a correlation between ALT levels and liver fibrosis [
We found no significant association between HBeAg status and liver fibrosis. HBeAg status was, however, associated with higher HBV DNA levels and the presence of HBeAg and hepatitis B viral load decreased with age. The correlation between HBV DNA levels and liver fibrosis is controversial. Croagh et al. reported that HBV DNA was an independent predictor for significant fibrosis in HBeAg− but not HBeAg+ patients [
Most previous studies have focused on predictors for liver fibrosis and the main driving force for the development of fibrosis appears to be active inflammation. In the present study, we examined routine parameters for predicting liver necroinflammatory disease. Our study showed that only ALB among the 15 variables was negatively correlated with advanced liver necroinflammatory disease. Age, ALB, AST, PLT, and PT were independently associated with significant fibrosis in different chronic HBV groups, that is, HBeAg− and HBeAg+ patients [
There are limitations of this study. HBV genotyping was not performed, which may have affected the results as previous small-scale studies found genotype C was associated with significant histological abnormalities [
In conclusion, ALT is a poor marker when considering antiviral therapy because of its poor correlation with significant liver injury in patients with chronic HBV infection. Lower levels of PLT were independently associated with significant fibrosis. If a liver biopsy is considered to assess disease activity and fibrosis, it can be recommended for patients with chronic HBV infection, particularly for an older age group and patients with normal ALT and lower PLT and ALB.
The authors have declared that no competing interests exist.
The authors have been supported by Science and Research Project Fund of Jiangsu Provincial Health Department No. H201059.