Michel BEAUGRAND EVALUATION OF LIVER FIBROSIS BLOOD TESTS

Michel BEAUGRAND

EVALUATION OF LIVER FIBROSIS BLOOD TESTS, LIVER BIOPSY AND FIBROSCAN M. Beaugrand Service d’Hépatologie Hopital J. Verdier BONDY 93143 et Université Paris XIII PHC JANUARY 07

EVALUATION OF FIBROSIS : WHY ? Fibrosis Distorted architecture Portal hypertension Causal agent FIBROSIS Chronic liver Disease Liver failure Carcinogenesis Cirrhosis Decompensation 2 % to 5 % per year Hepatocellular carcinoma 2 % to 5 % per year Death 4 % per year

ASSESSMENT OF FIBROSIS : WHY ? Management of individual patients • • Significant fibrosis Cirrhosis Treatment Screening for varices and HCC Evaluation of treatments • Antiviral and antifibrotic drugs Screening for cirrhosis or extensive fibrosis • In high risk patients

EVALUATION OF FIBROSIS : HOW ? - Liver biopsy - Blood tests • Genuine serum markers of fibrosis : by products of extracellular matrix metabolism. • Probabilistic indexes = surrogate markers. - Fibroscan ( transcient elastography)

LIVER BIOPSY : LIMITATIONS • • Acceptability - patients are often reluctant - even some doctors are reluctant Cost Morbidity Reliability - liver sample size ideally ≥ 25 mm - pathologist’s experience - suboptimal reproductibility of scoring systems - quantitative assessment unpractical

LENGH OF LIVER BIOPSY Biopsy length Bedossa et al, Hepatology 2003

LIVER BIOPSY : PROS AND CONS PRO. Not influenced by extrahepatic conditions. Allows analysis of elementary lesions and comobidities. May allow assessment of fibrogenesis (molecular biology) CON. Sampling error. Dependant of pathologist’s experience. Unavalaible in large parts of the world

BLOOD TESTS Matrix related PIIINP, collagen type IV, laminin Hyaluronic acid, MMP, TIMP Non maxtrix related AST, ALT, gamma GT Bilirubin, prothrombine, platelets Gammaglobulins, ferritin Alpha 2 macroglobulin, haptoglobin Apo A 1, cholesterol, HOMA

BLOOD TESTS Poynard, 1991 Prothrombine, GGT, Apo A 1 PGA Bonacini, 1997 AST/ALAT, platelets, prothrombine Imbert-Bismut, 2001 bili, GGT, hapto. , a 2 MG, apo. A 1 Fibrotest Luo, 2002 glob/alb, platelets, AST/ALT Forns, 2002 age, GGT, cholesterol, platelets Kaul, 2002 sex, ang. spider angiomas, AST, platelets Wai, 2003 AST/platelets APRI Sud, 2004 age, AST, cholesterol, HOMA, alcohol Lainé, 2004 hyaluronate, transferin Rosenberg, 2004 age, hyalur. , col IV, col VI, laminin, PIIINP, TIMP-1 ELF Patel, 2004 TIMP-1, a 2 MG, hyaluronate Fibrospect Leroy, 2004 PIIIMP, MMP 1 Hui, 2005 BMI, platelets, albumin, bilirubin Lok, 2005 AST/ALT, platelets, INR Adams, 2005 bili, GGT, hyaluronate, a 2 MG, age, sex Hepascore Cales, 2005 AST, platelets, prothrombine, hyaluronate, Fibrometre urea, age

BLOOD TESTS Fibrotest ® VHC (n= 339) index Imbert-Bismut et al. Lancet 2001; 357: 2069 -75 Metavir

BLOOD TESTS Fibrotest ® HCV (n=339) Métavir ≥ F 2 AUC = 0, 827 Index < 0, 10 Index > 0, 60 NPV 100% PPV > 90% Liver Biopsy: - 46% Imbert-Bismut et al. Lancet 2001; 357: 2069 -75

BLOOD TESTS HCV : F 0 -1 vs F 2 -3 -4 Ref. Imbert-Bismut, 2001 Test Fibrotest Forns, 2002 AUC Construction Validation 0. 83 0. 85 0. 86 0. 81 0. 88 Wai, 2003 Patel, 2004 APRI Fibrospect 0. 80 0. 83 Rosenberg, 2004 Leroy, 2004 ELF 0. 78 0. 82 Sud, 2004 Adams, 2005 Hepascore 0. 84 0. 85 0. 82

BLOOD TESTS HCV : F 0 -1 -2 -3 vs F 4 (cirrhosis) Ref. Test AUC Construction Kaul, 2002 Validation 0. 94 Wai, 2003 APRI 0. 89 Rosenberg, 2004 ELF 0. 89 Le Calvez, 2004 Fibrotest 0. 92 Adams, 2005 Hepascore 0. 94 0. 89 0. 78 0. 81 Lok, 2005 0. 94

BLOOD TESTS : PROS AND CONS PRO . Easy, non invasive, not too costy. Allow to split patients in 3 groups - those without significant fibrosis - those with extensive fibrosis or cirrhosis - intermediate CON . Studied mainly in naive patients with HCV chronic hepatitis. External validation lacking (except fibrotest). Require standardisation of biochemical methods. Poorer performances in HBV patients or coinfected HCV-HIV. Possible influence of extrahepatic conditions. No international consensus

ELASTOMETRY (FIBROSCAN) LB x 100 2. 5 cm Volume Probe 1 cm 4 cm Sandrin et al. Ultrasound Med Biol 2003; 29: 1 -8

HOW TO MEASURE ELASTICITY ? To generate an elastic Shear vawe To measure its spead Vs Elasticity E V S 2

Volume of exploration > 3 cm 3 Probe position Probe Volume of exploration 2. 5 cm 1 cm 4 cm

PATIENTS WITH HCV CHRONIC HEPATITIS 327 HCV + patients with no ascites 23 patients excluded: unreliable stiffness measurement: success rate less than 60% upon 10 measurements 53 patients excluded biopsy not suitable for fibrosis stage assessment: less than 10 portal tracts in the absence of cirrhosis 251 patients included Small biopsy 126 patients Large biopsy 125 patients

BOX PLOTS. N=251 Stiffness (k. Pa) (logarithmic scale) 100 Legend maximum 10 median minimum 1 0 -1 2 3 Fibrosis stage (METAVIR) 4 IQR

ROC CURVES AUROC ( CONFIDENCE INTERVALS 95%) F≥ 2 F≥ 3 F=4 - F≥ 2 : 0. 79 (0. 73 -0. 84) - F≥ 3 : 0. 91 (0. 87 -0. 96) - F=4 : 0. 97 (0. 93 -1. 00)

UNI AND MULTIVARIATE ANALYSIS Ø Univariate analysis (Kendall’s coefficient) Stiffness r p Fibrosis 0. 55 <0. 0001 Fibrosis r p - Activity 0. 21 0. 0003 Steatosis 0. 19 0. 0008 0. 36 <0. 0001 0. 17 0. 008 Ø Multivariate analysis (multiple regression) Only fibrosis was significantly correlated to liver stiffness measurement.

VALIDATION OF DIAGNOSIS ACCURACY IN AN INDEPENDENT HCV POPULATION Total number of included patients: 639 Number of unreliable liver samples: 86 (13%) Number of unreliable LSM: 59 (9%) Patients kept for statistical analysis : 494 F % METAVIR A % 0 6 S 0 Steatosis % 47 1 39 1 56 110 27 2 31 2 35 1130 15 Univariate Spearman correlation METAVIR F: 0. 70 (p << 0. 001) METAVIR A: 0. 45 (p << 0. 001) Steatosis: 0. 35 (p << 0. 001) 3 10 3 3 31100 10 4 14 Area under ROC curves (95% confidence interval) F 01 versus F 234 = 0. 84 (0. 80 -0. 87) F 012 versus F 34 = 0. 93 (0. 90 -0. 95) F 0123 versus F 4 = 0. 96 (0. 94 -0. 98)

LIVER BIOPSIES > 30 mm - 103 Patients Causes : - Results AUROC 71 VHC 14 VHB 15 VHC+HIV 2 VHB+HIV 1 VHC+VHB Fibrosis Score : N F 0 F 1 F 2 F 3 F 4 9 58 14 7 15 F 2 F 3 = F 4 0. 95 0. 93

CUT-OFF VALUES* The optimum thresholds were chosen to maximize the sum of sensitivity and specificity. F 2 F 3 F=4 Threshold Sensitivity Specificity LR (k. Pa) 8. 7 0. 55 0. 84 3. 5 9. 6 0. 84 0. 85 5. 7 14. 5 0. 84 0. 94 13. 0 * Obtained by the jack-knife method.

FIBROSIS AREA (morphometry) - Patients 69 patients with chronic hepatitis C without ascites, and previous anti-viral treatment METAVIR - Results F 1 20 F 2 21 F 3 5 F 4 23 Spearman correlation test p < 0. 001 Parameters Fibrosis area METAVIR score Elasticity fibrosis area Liver elasticity is closely correlated to fibrosis area. r 0. 66 0. 65 0. 74

FIBROSCAN VERSUS BLOOD TESTS Fibro. Test APRI Elasticité (k. Pa) Fibro. Scan Score METAVIR de fibrose Castera Al. Gastroenterology 2005

CONCORDANCE WITH LIVER BIOPSY • AUROC F 01/F 234 APRI 0. 78 Fibro. Test 0. 85 Fibro. Scan 0. 83 Combinaison 0. 88 Fibro. Test+Fibro. Scan F 012/F 34 0. 84 0. 90 0. 95 F 0123/F 4 0. 83 0. 87 0. 95 • Percentage of concording results F 01/F 234 Fibro. Test 80 Fibro. Scan 73 Combinaison 84 Fibro. Test+Fibro. Scan F 0123/F 4 81 83 95

PROPOSED COMBINATION OF NON INVASIVE METHODS Fibro. Scan + Fibro. Test Concordance Discordance Biopsy Fibrose minime (FS < 7. 1 k. Pa + FT < F 2) Fibrose modérée (FS 7. 1 k. Pa + FT F 2) Fibrose sévère (FS 9. 5 k. Pa + FT F 3) Follow-up treatment Follow-up Treatment HCC screening Castera et Al. Gastroenterlogy 2005

FIBROSCAN IN HBV PATIENTS 202 patients - 15 non interpretable biopsies - 14 LSM considered as non reliable Statistical analysis on 173 patients AUROC F 01 versus F 234: 0. 81 (0. 73 -0. 86) F 012 versus F 34: 0. 93 (0. 88 -0. 96) F 0. 123 versus F 4: 0. 93 (0. 82 -0. 98)

FIBROSCAN PROS AND CONS § PRO -easy, quick, not too costy - very specific for extensive fibrosis or cirrhosis - Allows to split patients between 3 groups. Without significant fibrosis. With extensive fibrosis or cirrhosis. Intermediate - closely related to the area of fibrosis in patients with chronic hepatitis § CON - high rate of failure in obese patients - doesn’t take in account liver architecture - disturbed in acute conditions

SCREENING IN HIGH RISK PATIENTS LSM 227 patients in alcoholic abstinence program LSM>13 k. Pa oui Suspected cirrhosis 41 LB 34 Blood tests non Absence of cirrhosis Confirmation of cirrhosis 33

FOLLOW-UP OF LSM IN TREATED PATIENTS WITH CHRONIC HEPATITIS C BEFORE END OF 6 MONTHS TREATMEN AFTER T T All (n=85) 14. 1 ± 7. 2 10. 9 ± 6. 5 11. 2 ± 8. 6 SVR 12. 0 ± 6. 7 9. 1 ± 3. 7 7. 5 ± 2. 4 RR 14. 6 ± 5. 6 11. 5 ± 5. 0 12. 8 ± 7. 2 NR 16. 9 ± 8. 1 13. 3 ± 9. 1 16. 1 ± 12. 2

CONCLUSION 1) Liver biopsy has been partly challenged by non invasive methods for assessment of liver fibrosis 2) Non invasive methods have their own limitations : 2 might be better than one 3) Fibroscan could become a useful tool for assessing fibrosis variations