Predictors of Histologic Severity in Chronic Hepatitis B-infected Patients

J Exp Clin Med 2011;3(6):300e303

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SHORT COMMUNICATION

Predictors of Histologic Severity in Chronic Hepatitis B-infected Patientsq Victor Araya 1 y *, Eyob L. Feyssa 1 y, Afshin Parsikia 2 y, Ashaur Azhar 1 y, Laxmi Thummalakunta 1 y, Nikroo Hashemi 1 y, Puneet Basi 1 y, Jorge Ortiz 2 y 1 2

Division of Hepatology, Center for Liver Disease and Transplantation, Albert Einstein Healthcare Network Program, Philadelphia, PA, USA Department of Transplant Surgery, Center for Liver Disease and Transplantation, Albert Einstein Healthcare Network Program, Philadelphia, PA, USA

a r t i c l e i n f o Article history: Received: Oct 7, 2011 Accepted: Oct 24, 2011 KEY WORDS: chronic hepatitis B; predicting advanced disease; treatment algorithm

The role of liver biopsy in chronic Hepatitis B treatment guidelines remains incompletely defined. Our aim was to correlate histologic disease severity with demographic, biochemical and virologic parameters as currently used in Hepatitis B treatment guidelines. We conducted an Institutional Review Board (IRB) approved retrospective cross-sectional study of chronic Hepatitis B patients between January 2001 and July 2009. Patients with at least two Alanine Aminotransferase (ALT) values (6 months apart), with detectable Hepatitis B DNA quantitative levels at the time of initial evaluation, unchanged HBeAg status over a minimum of 6 months but no prior history of antiviral therapy, alcohol abuse, co-infection, hepatocellular carcinoma, iron overload or liver decompensation were reviewed. Advanced histological disease was defined as a METAVIR score of greater than or equal to stage and/or grade 3 (S/G 3). Multivariable binary logistic regression was used to determine the independent predictors of advanced histology. One hundred and twenty-eight patients met inclusion criteria. On multivariate logistic regression analysis, viral load was not an independent predictor. However, age 40, abnormal ALT and HBeAg(þ) were independent predictors of S/G3. Controlling for ALT and HBeAg status, patients 40 years old had 14.5 times the adjusted odds of S/G3 (95% CI, 4.24e49.54) while 31% of HBeAg(-) /Low Viral load patients had S/G3. Current HBVtreatment guidelines do not fully predict advanced histological disease. In the group where all the current guidelines recommend observation without treatment, one third had advanced histology on liver biopsy. Copyright Ó 2011, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction The prevalence of chronic hepatitis B (CHB) is estimated to be 350 to 400 million patients.1 At least 1.25 million cases are in the US.2 In the US, most de novo Hepatitis B virus (HBV) infections occur in adolescence and early adulthood but in Asia most occur via vertical transmission. Despite an aggressive policy of vaccination and treatment, immigration from endemic areas of the world has contributed to this significant disease burden. It is estimated that 15e40% of patients will develop serious sequelae of advanced liver disease during their lifetime.3,4 Timely and appropriate antiviral therapy is crucial to prevent complications, such as cirrhosis and q Financial disclosure: In the context of this study, we have no relationship that could be perceived as a potential conflict of interest. * Corresponding author. 5501 Old York Road, Klein Building Suite 509, Philadelphia, PA 19141, USA. E-mail: V. Araya y Author contribution: Victor Araya, Eyob L. Feyssa, Afshin Parsikia, Ashaur Azhar and Laxmi Thummalakunta prepared the manuscript; Eyob L. Feyssa, Ashaur Azhar, Nikroo Hashemi, Puneet Basi, Jorge Ortiz and Victor Araya were involved in collecting the data and analyzing the same.

hepatocellular carcinoma (HCC).3 However, the appropriateness and timing of treatment remain incompletely defined. Published CHB treatment guidelines5e10 advocate treatment decisions based on the ALT, HBeAg, and viral load (VL) status. Age was recently added to the US guidelines as a relatively minor component. Presently, a liver biopsy is suggested for those who do not meet clear-cut criteria for treatment.5 The accuracy of these criteria have been questioned as a significant number of patients with or at risk for advanced liver disease or HCC may be excluded from treatment consideration when the guidelines are applied.9 Little data exist linking treatment algorithms with histologic severity in HBV infected patients. It is possible that HBV infected patients with ALT values close to the upper limit of normal may have abnormal histology and are, therefore, at an increased risk of morbidity. With little supporting data, age of 40 has been added to some treatment guidelines to aid with treatment decisions.5 However, a histologic evaluation with a liver biopsy remains the most accurate indicator of liver disease severity and, historically, it has been a fundamental tool to determine prognosis.11 The specific aim of our study was to assess how the demographic, biochemical, serological and virological parameters used in

1878-3317/$ e see front matter Copyright Ó 2011, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.jecm.2011.10.015

Predictors of advanced liver disease in chronic hepatitis B

HBV-treatment algorithms reflect histological disease severity in CHB-infected patients. 2. Patients and methods We conducted an IRB approved retrospective review of all HBV infected patients referred to our center between January 2001 and July 2009. HBV infected patients with at least two ALT values (6 months apart), with detectable HBV DNA quantitative levels at the time of initial evaluation, unchanged HBeAg status over a minimum of 6 months and also a liver biopsy within 2 years of the collection of serological data. At our center, it has been our practice to routinely biopsy all patients with HBV infection and detectable viremia. Patients co-infected with HIV, HDV or HCV, on immunosuppression, other underlying liver disorders, alcohol abuse, evidence of iron overload, HCC or prior antiviral therapy before biopsy were excluded from data analysis. Demographic, biochemical (ALT), serological (HBeAg status), VL and histologic data were collected for analysis. Laboratory reference values were used to define abnormal ALT (>1  ULN). Patients were classified based on VL and HBe Ag status. High Viral Load (HVL) was defined as HBV DNA level of 2000 IU/mL in HBeAg(e) patients or 20,000 IU/mL in HBeAg(þ) patients. A Low Viral Load (LVL) was defined as HBV DNA level of <2000 IU/mL in HBeAg(-) patients or <20,000 IU/mL in HBeAg(þ) patients. METAVIR scoring was used for histologic analysis. Grade (G) indicates the activity of necroinflammation and Stage (S) represents the fibrosis score. A necroinflammatory score of 3 (A3) or more and/or fibrosis score of 3 (F3) or more was defined as an advanced histological liver disease ( S/G3). The liver biopsies were interpreted by multiple experienced liver pathologists at the time of the liver biopsy following the same standard reporting guidelines. To simulate the existing CHB treatment algorithms, we classified our patients into four groups based on the HBeAg status and viral load levels. Group A: HBeAg(-) and LVL, Group B: HBeAg(-) and HVL, Group C: HBeAg(þ) and LVL and Group D: HBeAg(þ) and HVL. 3. Data analysis and statistics Categorical variables were compared with c2 test and continuous variables with student’s t test. All statistical significance was assessed at 95% confidence intervals. Multivariable binary logistic regression were used to determine the independent predictors of CHB patients being S/G3 on liver biopsy with the area under the receiver operator characteristic curve (AROC) indicating the predictive accuracy of that model. The Pearson c2 tested the goodness of fit of the model. All statistical analysis was performed using the SPSS statistical software for windows Ver. 11.0 (SPSS, Chicago, IL, USA). P < 0.05 was considered significant. 4. Results Seven hundred and seventy-nine patients had Chronic Hepatitis B infection. A total of 128 patients met the inclusion criteria. Table 1 shows demographic and clinical characteristics of these patients. The mean (SD) age at presentation was 46.4 (12.7) years and 66% of patients were 40 years of age or older. Over all, 77 (60.2%) patients were males and 70 (54.7%) patients were Asians. Twentyfive (19.5%) patients in the study group were Vietnamese in origin. Only 55 (43%) of patients had an abnormal ALT based on the laboratory reference value. Similarly, 54 (42.2%) patients had HVL and the rest 74 (57.8%) patients had a LVL. Of the total, 41 (32%) patients were HBeAg(þ) at the time of presentation. Table 2 shows the clinical, biochemical, and histological characteristics of the patients according to their HBeAg status. We

301 Table 1 Demographic and clinical characteristics of study CHB patients Variable

n (%)

Age 40 RACE Asian (Vietnamese) Asian (Chinese) Asian (Cambodian) Asian (Other) African Americans Caucasians/White Hispanics Other

85 (66.4) 25 (19.5) 10 (7.8) 7 (5.5) 28 (21.9) 28 (21.9) 16 (12.5) 4 (3.1) 10 (7.8)

GENDER Male Female

77 (60.2) 51 (39.8)

ALT Normal ALT Abnormal ALT

73 (57.0) 55 (43.0)

VIRAL LOAD Low viral load (LVL) High viral load (HVL)

74 (57.8) 54 (42.2)

HBeAg þ Status

41 (32.0)

Biopsy Grade and Stage: grade 3 stage 3 Advanced Disease (S/G3)

29 (22.6) 41 (32.0) 50 (39.1)

Group A: HBeAg(-) and LVL B: HBeAg(-) and HVL C: HBeAg(þ) and LVL D: HBeAg(þ) and HVL

67 (52.3) 20 (15.6) 7 (5.5) 34 (26.6)

High Viral Load (HVL): HBV DNA level of  2000 IU/mL in HBeAg(-) or  20,000 IU/mL in HBeAg(þ). Low Viral Load (LVL): HBV DNA level of < 2000 IU/mL in HBeAg(-) or < 20,000 IU/mL in HBeAg(þ).

found no difference in the rate of gender or race/ethnicity between HBeAg positive and negative patients. We also did not see a significant difference in the rate of abnormal ALT between the HBeAg groups. Our HBeAg(þ) patients did tend to be younger than 40 years of age and to have HVL compared to the HBeAg(-) patients (p < 0.01). The presence of advanced liver disease histology was evaluated in all patients. Overall, 39% of patients had advanced liver histology ( S/G3); 51% of HBeAg(þ) patients and 33% of HBeAg(-) patients (Table 2). Twenty-six (20%) patients had cirrhosis at the time of presentation. Demographic, biochemical and virologic variables were compared between histology groups (Table 3). Three variables, an abnormal ALT value, HBeAg(þ) status and age 40 years were independently associated with the presence of advanced liver disease histology ( S/G3). Patient age 40 years conferred greatest risk for advanced liver disease [Odds ratio (OR), 14.5; 95% Table 2 Demographic and clinical characteristics of CHB patients by HBeAg status Variable

HBeAg Negative [n (%)]

HBeAg Positive [n (%)]

p value

Male Age 40 Asian HVL Abnormal ALT Advanced Disease ( S/G3)

54 66 44 20 37 29

23 19 26 34 18 21

0.325 0.001 0.120 0.000 0.517 0.041

(62.1) (75.9) (50.6) (23.0) (42.5) (33.3)

(56.1) (46.3) (63.4) (82.9) (43.9) (51.2)

High Viral Load (HVL): HBV DNA level of  2000 IU/mL in HBeAg(-) or  20,000 IU/ mL in HBeAg(þ). Low Viral Load (LVL): HBV DNA level of < 2000 IU/mL in HBeAg(-)or < 20,000 IU/mL in HBeAg(þ).

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V. Araya et al.

Table 3 Univariate and multivariate analysis of patient characteristics to predict presence of advanced liver disease ( S/G3) Variable

Univariate analysis OR (95% CI)

p value

Gender Female Male

1 (reference) 2.0 (0.94e4.24)

0.07

Age Age < 40 Age  40

1 (reference) 5.27 (2.11e13.14)

<0.001

Race/Ethnicity NonAsian Asian

1 (reference) 0.56 (0.27e1.15)

0.115

Viral Load Low (LVL) High (HVL)

1 (reference) 1.48 (0.72e3.03)

0.287

HBeAg Status HBeAg(-) HBeAg(þ)

1 (reference) 2.10 (1.01e4.48)

ALT Value Normal Abnormal

1 (reference) 2.76 (1.33e5.75)

Multivariate analysis OR (95% CI)

p value

1 (reference) 14.50 (4.24e49.54)

<0.001

0.049

1 (reference) 6.38 (2.13e19.13)

0.001

0.007

1 (reference) 3.76 (1.60e8.81)

0.002

confidence interval (CI), 4.24e49.54] followed by HBeAg(þ) state (OR, 6.38; 95% CI, 2.13e19.13) and abnormal ALT value (OR, 3.76; 95% CI, 1.60e8.81). Patient’s gender, race/ethnic group and HBV VL were not independent predictors of S/G3. In addition HBV VL does not correlate with the grade or stage on liver histology. Advanced liver disease histology was seen in 31% of Group A CHB patients. These patients who were HBeAg(-) with LVL would not meet criteria to initiate antiviral therapy under any treatment guidelines without a biopsy. Interestingly the lowest rate of S/G3 (þ) patients was found in group C (HBeAg positive and LVL patients). The median age for group C patients was 52 years (range 19e70 years) and 85.7% of these patients also had a normal ALT. Taken together, the three variables, an abnormal ALT value, HBeAg positive state and age 40 years were able to correctly identify the histologic severity in majority of CHB cases [Area under the receiver operating characteristic curve (AROC) of 76%]. 5. Discussion Multiple studies in CHB patients have shown that patients with low viral load,12 normal or high normal ALT13,14 may still have advanced disease histology on liver biopsy. This poor correlation between minimally-invasive blood tests and the liver biopsy has prompted us to design this study to devise a reliable diagnostic model of appropriate CHB treatment. Since we began this project there have been several pivotal developments which have augmented our understanding of the natural history of CHB. The REVEAL study group documented HVL as predictor of cirrhosis and HCC.15 On the other hand, other smaller cross-sectional studies which focused on the initial evaluation of CHB patients failed to show this VL association.16,17 Similarly, in our study high serum HBV DNA levels were not correlated with significant histological grade and stage of the liver disease. Histological assessment however, was not uniformly done in the REVEAL study at the time of study initiation. El-Zayadi et al18 studied 52 HBeAg(-) CHB patients who had LVL and low ALT. Significant fibrosis ( F2) was found in 26% with LVL and 53% with low ALT levels. In our study, advanced histology ( S/G3) was found in 31% of patients with HBeAg(-)/LVL. Other studies also documented similar results.19 In these studies the liver biopsy increased eligibility for treatment by 55.8%. In our study the

liver biopsy increased eligibility for treatment by 33.4% when using the more conservative standard of stage 3 and/or grade 3. Failure to treat patients with advanced histology will lead to cirrhosis and an increased incidence of HCC. Our study suggests that abnormal ALT, eAg status and age 40 years can be strong predictors for advanced histology. Age 40 years was found to be the strongest independent predictor of advanced histology on univariate analysis. The serologic variables used in our study are standard variables already part of most guidelines. They have the advantage of being easily collected on a routine basis in any clinical setting. However, they appear to be insufficient in identifying all patients already at advanced stages of disease. Although the liver biopsy suffers from its invasive nature and inherent sampling errors, our observations suggests that its judicious use in hepatitis B-infected patients should be emphasized more strongly in current treatment guidelines. Unfortunately, the risks associated with it may limit its universal application in all HBV-infected patients. Other noninvasive methods, such as transient elastography,20 need further study in this population. Our study has demonstrated that without a more aggressive histological assessment a substantial number of patients who may benefit from treatment will not receive it using current treatment guidelines. CHB infected patients age 40 and above will benefit from detailed histologic assessment of their liver disease despite their eAg status and ALT level. The presence of HBeAg and elevated ALT should prompt practitioners to consider a biopsy in order to determine the need for treatment and to stage the disease more accurately. Because of its retrospective nature this report has some important issues with its design that deserve more attention. First, our study population mirrors a major American metropolitan area with ethnic diversity. This patient population is, therefore, more diverse than those reported in other trials trying to answer similar questions. We also did not have genotype data. The genotype data on histological correlation is limited at this time and was not available from commercial laboratories during the time period of our data generation. It was also not standard of care and was not included in any HBV treatment guidelines. The definition of normal ALT was based on the normal range as defined by commercial laboratories and not by the recent recommendations for Asians. Because of the ethnic diversity of our cohort it was not clear if the recently proposed normal values (ALT 20 for women and ALT 30 for men) would apply to the nonAsian patients. Our decision to use stage 3 and or grade 3 in our definition of advanced histology is more conservative and beyond the more commonly used stage 2 and or grade 2 used to decide eligibility for treatment in other liver diseases, such as Hepatitis C. The intention was to use a conservative stage or grade to try to circumvent inter observer bias as well as to diminish the possibility of continuing controversy as to whether these patients deserve treatment. In summary, our observations and analysis suggests that age 40 years is the strongest predictor of advanced histology independent of HBeAg status and ALT. In our study, VL did not predict disease severity. One third of patients with HBeAg(-) /Low VL can have advanced histological disease but would not be candidates for antiviral therapy based on current guidelines. We suggest that age should be incorporated as a stronger factor when making management decisions in CHB. Histological assessment in the form of a liver biopsy should perhaps be part of the evaluation of patients over 40 years of age as it seems to be a more decisive measure of disease severity than the currently recommended biochemical or virologic data delineated in treatment algorithms for CHB infected patients. Further studies are needed to validate our preliminary data. These studies should also evaluate the effect of genotyping on predictors of histological findings to help with treatment decisions.

Predictors of advanced liver disease in chronic hepatitis B

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