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

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Journal of Experimental and Clinical Medicine

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SHORT COMMUNICATION

Predictors of Histologic Severity in Chronic Hepatitis B-infected Patientsq

Victor Araya 1y*, Eyob L. Feyssa 1y, Afshin Parsikia 2y, Ashaur Azhar 1y, Laxmi Thummalakunta 1y,Nikroo Hashemi 1y, Puneet Basi 1y, Jorge Ortiz 2y

1Division of Hepatology, Center for Liver Disease and Transplantation, Albert Einstein Healthcare Network Program, Philadelphia, PA, USA2Department 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, 2011Accepted: Oct 24, 2011

KEY WORDS:chronic hepatitis B;predicting advanced disease;treatment algorithm

q Financial disclosure: In the context of this study,could be perceived as a potential conflict of interest.* Corresponding author. 5501 Old York Road,

Philadelphia, PA 19141, USA.E-mail: V. Araya <ArayaV@einstein.edu>

y Author contribution: Victor Araya, Eyob L. Feyssa,and Laxmi Thummalakunta prepared the manuscript;Nikroo Hashemi, Puneet Basi, Jorge Ortiz and Victorlecting the data and analyzing the same.

1878-3317/$ e see front matter Copyright � 2011, Tadoi:10.1016/j.jecm.2011.10.015

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 virologicparameters as currently used in Hepatitis B treatment guidelines. We conducted an InstitutionalReview Board (IRB) approved retrospective cross-sectional study of chronic Hepatitis B patientsbetween 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 initialevaluation, unchanged HBeAg status over a minimum of 6 months but no prior history of antiviraltherapy, alcohol abuse, co-infection, hepatocellular carcinoma, iron overload or liver decompensationwere reviewed. Advanced histological disease was defined as a METAVIR score of greater than orequal to stage and/or grade 3 (�S/G 3). Multivariable binary logistic regression was used to deter-mine the independent predictors of advanced histology. One hundred and twenty-eight patients metinclusion criteria. On multivariate logistic regression analysis, viral load was not an independentpredictor. 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 HBV-treatment guidelines do not fully predict advanced histological disease. In the group where all thecurrent guidelines recommend observation without treatment, one third had advanced histology onliver biopsy.

Copyright � 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 350to 400 million patients.1 At least 1.25 million cases are in the US.2 Inthe US, most de novo Hepatitis B virus (HBV) infections occur inadolescence and early adulthood but in Asia most occur via verticaltransmission. Despite an aggressive policy of vaccination andtreatment, immigration from endemic areas of the world hascontributed to this significant disease burden. It is estimated that15e40% of patients will develop serious sequelae of advanced liverdisease during their lifetime.3,4 Timely and appropriate antiviraltherapy is crucial to prevent complications, such as cirrhosis and

we have no relationship that

Klein Building Suite 509,

Afshin Parsikia, Ashaur AzharEyob L. Feyssa, Ashaur Azhar,Araya were involved in col-

ipei Medical University. Published

hepatocellular carcinoma (HCC).3 However, the appropriatenessand timing of treatment remain incompletely defined.

Published CHB treatment guidelines5e10 advocate treatmentdecisions based on the ALT, HBeAg, and viral load (VL) status. Agewas recently added to the US guidelines as a relatively minorcomponent. Presently, a liver biopsy is suggested for those who donot meet clear-cut criteria for treatment.5 The accuracy of thesecriteria have been questioned as a significant number of patientswith or at risk for advanced liver disease or HCC may be excludedfrom treatment consideration when the guidelines are applied.9

Little data exist linking treatment algorithms with histologicseverity in HBV infected patients. It is possible that HBV infectedpatients with ALT values close to the upper limit of normal mayhave abnormal histology and are, therefore, at an increased risk ofmorbidity. With little supporting data, age of 40 has been added tosome treatment guidelines to aid with treatment decisions.5

However, a histologic evaluation with a liver biopsy remains themost accurate indicator of liver disease severity and, historically, ithas been a fundamental tool to determine prognosis.11

The specific aim of our study was to assess how the demo-graphic, biochemical, serological and virological parameters used in

by Elsevier Taiwan LLC. All rights reserved.

Table 1 Demographic and clinical characteristics of study CHBpatients

Variable n (%)

Age �40 85 (66.4)RACEAsian (Vietnamese) 25 (19.5)Asian (Chinese) 10 (7.8)Asian (Cambodian) 7 (5.5)Asian (Other) 28 (21.9)African Americans 28 (21.9)Caucasians/White 16 (12.5)Hispanics 4 (3.1)Other 10 (7.8)

GENDERMale 77 (60.2)Female 51 (39.8)

ALTNormal ALT 73 (57.0)Abnormal ALT 55 (43.0)

VIRAL LOADLow viral load (LVL) 74 (57.8)High viral load (HVL) 54 (42.2)

HBeAgþ Status 41 (32.0)

Biopsy Grade and Stage:�grade 3 29 (22.6)�stage 3 41 (32.0)Advanced Disease (�S/G3) 50 (39.1)

GroupA: HBeAg(-) and LVL 67 (52.3)B: HBeAg(-) and HVL 20 (15.6)C: HBeAg(þ) and LVL 7 (5.5)D: HBeAg(þ) and HVL 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).

Table 2 Demographic and clinical characteristics of CHB patients by HBeAg status

Variable HBeAg Negative[n (%)]

HBeAg Positive[n (%)]

p value

Male 54 (62.1) 23 (56.1) 0.325Age �40 66 (75.9) 19 (46.3) 0.001Asian 44 (50.6) 26 (63.4) 0.120HVL 20 (23.0) 34 (82.9) 0.000Abnormal ALT 37 (42.5) 18 (43.9) 0.517Advanced Disease (� S/G3) 29 (33.3) 21 (51.2) 0.041

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/mLin HBeAg(þ).

Predictors of advanced liver disease in chronic hepatitis B 301

HBV-treatment algorithms reflect histological disease severity inCHB-infected patients.

2. Patients and methods

We conducted an IRB approved retrospective review of all HBVinfected patients referred to our center between January 2001 andJuly 2009. HBV infected patients with at least two ALT values(6 months apart), with detectable HBV DNA quantitative levels atthe time of initial evaluation, unchanged HBeAg status overaminimum of 6months and also a liver biopsywithin 2 years of thecollection of serological data. At our center, it has been our practiceto routinely biopsy all patients with HBV infection and detectableviremia. Patients co-infected with HIV, HDV or HCV, on immuno-suppression, other underlying liver disorders, alcohol abuse,evidence of iron overload, HCC or prior antiviral therapy beforebiopsy were excluded from data analysis.

Demographic, biochemical (ALT), serological (HBeAg status), VLand histologic datawere collected for analysis. Laboratory referencevalues were used to define abnormal ALT (>1�ULN). Patients wereclassified based on VL and HBe Ag status. High Viral Load (HVL) wasdefined 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) wasdefined as HBV DNA level of <2000 IU/mL in HBeAg(-) patients or<20,000 IU/mL in HBeAg(þ) patients. METAVIR scoring was usedfor histologic analysis. Grade (G) indicates the activity of necro-inflammation and Stage (S) represents the fibrosis score. A nec-roinflammatory score of 3 (A3) or more and/or fibrosis score of3 (F3) or more was defined as an advanced histological liver disease(� S/G3). The liver biopsies were interpreted by multiple experi-enced liver pathologists at the time of the liver biopsy following thesame standard reporting guidelines.

To simulate the existing CHB treatment algorithms, we classifiedour patients into four groups based on the HBeAg status and viralload 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 continuousvariables with student’s t test. All statistical significance wasassessed at 95% confidence intervals. Multivariable binary logisticregression were used to determine the independent predictors ofCHB patients being �S/G3 on liver biopsy with the area underthe receiver operator characteristic curve (AROC) indicating thepredictive accuracy of that model. The Pearson c2 tested thegoodness of fit of the model. All statistical analysis was performedusing 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 Binfection. A total of 128 patients met the inclusion criteria. Table 1shows demographic and clinical characteristics of these patients.The mean (�SD) age at presentation was 46.4 (�12.7) years and66% of patients were 40 years of age or older. Over all, 77 (60.2%)patients were males and 70 (54.7%) patients were Asians. Twenty-five (19.5%) patients in the study group were Vietnamese in origin.Only 55 (43%) of patients had an abnormal ALT based on thelaboratory reference value. Similarly, 54 (42.2%) patients had HVLand 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 char-acteristics of the patients according to their HBeAg status. We

found no difference in the rate of gender or race/ethnicity betweenHBeAg positive and negative patients. We also did not seea significant difference in the rate of abnormal ALT between theHBeAg groups. Our HBeAg(þ) patients did tend to be younger than40 years of age and to have HVL compared to the HBeAg(-) patients(p< 0.01).

The presence of advanced liver disease histology was evaluatedin 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 ofpresentation.

Demographic, biochemical and virologic variables werecompared between histology groups (Table 3). Three variables, anabnormal ALT value, HBeAg(þ) status and age �40 years wereindependently associated with the presence of advanced liverdisease histology (� S/G3). Patient age�40 years conferred greatestrisk for advanced liver disease [Odds ratio (OR), 14.5; 95%

Table 3 Univariate and multivariate analysis of patient characteristics to predictpresence of advanced liver disease (� S/G3)

Variable Univariate analysis Multivariate analysis

OR (95% CI) p value OR (95% CI) p value

GenderFemale 1 (reference) 0.07Male 2.0 (0.94e4.24)

AgeAge < 40 1 (reference) <0.001 1 (reference) <0.001Age � 40 5.27 (2.11e13.14) 14.50 (4.24e49.54)

Race/EthnicityNonAsian 1 (reference) 0.115Asian 0.56 (0.27e1.15)

Viral LoadLow (LVL) 1 (reference) 0.287High (HVL) 1.48 (0.72e3.03)

HBeAg StatusHBeAg(-) 1 (reference) 0.049 1 (reference) 0.001HBeAg(þ) 2.10 (1.01e4.48) 6.38 (2.13e19.13)

ALT ValueNormal 1 (reference) 0.007 1 (reference) 0.002Abnormal 2.76 (1.33e5.75) 3.76 (1.60e8.81)

V. Araya et al.302

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 VLwere not independent predictors of�S/G3. In addition HBV VL doesnot correlate with the grade or stage on liver histology.

Advanced liver disease histology was seen in 31% of Group ACHB patients. These patients who were HBeAg(-) with LVL wouldnot meet criteria to initiate antiviral therapy under any treatmentguidelines without a biopsy. Interestingly the lowest rate of S/G3(þ) patients was found in group C (HBeAg positive and LVLpatients). The median age for group C patients was 52 years (range19e70 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 correctlyidentify the histologic severity in majority of CHB cases [Area underthe receiver operating characteristic curve (AROC) of 76%].

5. Discussion

Multiple studies in CHB patients have shown that patients with lowviral load,12 normal or high normal ALT13,14 may still have advanceddisease histology on liver biopsy. This poor correlation betweenminimally-invasive blood tests and the liver biopsy has promptedus to design this study to devise a reliable diagnostic model ofappropriate CHB treatment.

Since we began this project there have been several pivotaldevelopments which have augmented our understanding of thenatural history of CHB. The REVEAL study group documented HVLas predictor of cirrhosis and HCC.15 On the other hand, othersmaller cross-sectional studies which focused on the initial evalu-ation of CHB patients failed to show this VL association.16,17 Simi-larly, in our study high serum HBV DNA levels were not correlatedwith significant histological grade and stage of the liver disease.Histological assessment however, was not uniformly done in theREVEAL study at the time of study initiation.

El-Zayadi et al18 studied 52 HBeAg(-) CHB patients who had LVLand low ALT. Significant fibrosis (� F2) was found in 26% withLVL and 53% with low ALT levels. In our study, advanced histology(� S/G3) was found in 31% of patients with HBeAg(-)/LVL. Otherstudies also documented similar results.19 In these studies the liverbiopsy increased eligibility for treatment by 55.8%. In our study the

liver biopsy increased eligibility for treatment by 33.4% when usingthe more conservative standard of stage 3 and/or grade 3.

Failure to treat patients with advanced histology will lead tocirrhosis and an increased incidence of HCC. Our study suggeststhat abnormal ALT, eAg status and age �40 years can be strongpredictors for advanced histology. Age �40 years was found to bethe strongest independent predictor of advanced histology onunivariate analysis.

The serologic variables used in our study are standard variablesalready part of most guidelines. They have the advantage of beingeasily collected on a routine basis in any clinical setting. However,they appear to be insufficient in identifying all patients already atadvanced stages of disease. Although the liver biopsy suffers fromits invasive nature and inherent sampling errors, our observationssuggests that its judicious use in hepatitis B-infected patientsshould be emphasized more strongly in current treatment guide-lines. Unfortunately, the risks associated with it may limit itsuniversal application in all HBV-infected patients. Other noninva-sive methods, such as transient elastography,20 need further studyin this population.

Our study has demonstrated that without a more aggressivehistological assessment a substantial number of patients who maybenefit from treatment will not receive it using current treatmentguidelines. CHB infected patients age 40 and above will benefit fromdetailed histologic assessment of their liver disease despite their eAgstatus and ALT level. The presence of HBeAg and elevated ALT shouldprompt practitioners to consider a biopsy in order to determine theneed for treatment and to stage the disease more accurately.

Because of its retrospective nature this report has someimportant issues with its design that deserve more attention. First,our study population mirrors a major American metropolitan areawith ethnic diversity. This patient population is, therefore, morediverse than those reported in other trials trying to answer similarquestions. We also did not have genotype data. The genotype dataon histological correlation is limited at this time and was notavailable from commercial laboratories during the time period ofour data generation. It was also not standard of care and was notincluded in any HBV treatment guidelines. The definition of normalALT was based on the normal range as defined by commerciallaboratories and not by the recent recommendations for Asians.Because of the ethnic diversity of our cohort it was not clear if therecently proposed normal values (ALT 20 for women and ALT 30 formen) would apply to the nonAsian patients. Our decision to usestage 3 and or grade 3 in our definition of advanced histology ismore conservative and beyond the more commonly used stage 2and or grade 2 used to decide eligibility for treatment in other liverdiseases, such as Hepatitis C. The intention was to use a conserva-tive stage or grade to try to circumvent inter observer bias as well asto diminish the possibility of continuing controversy as to whetherthese patients deserve treatment.

In summary, our observations and analysis suggests that age�40 years is the strongest predictor of advanced histology inde-pendent of HBeAg status and ALT. In our study, VL did not predictdisease severity. One third of patients with HBeAg(-) /Low VL canhave advanced histological disease but would not be candidatesfor antiviral therapy based on current guidelines. We suggest thatage should be incorporated as a stronger factor when makingmanagement decisions in CHB. Histological assessment in the formof a liver biopsy should perhaps be part of the evaluation of patientsover 40 years of age as it seems to be a more decisive measure ofdisease severity than the currently recommended biochemical orvirologic data delineated in treatment algorithms for CHB infectedpatients. Further studies are needed to validate our preliminarydata. These studies should also evaluate the effect of genotyping onpredictors of histological findings to help with treatment decisions.

Predictors of advanced liver disease in chronic hepatitis B 303

However, less invasive methodologies for histological assessmentneed to be used to facilitate this important step in the evaluation fortreatment.

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