The Role of Liver Fibrosis Assessment in the Management of Patients with Chronic Hepatitis B Infection: Lessons Learned from a Single Centre Experience
Background & Aims. Assess the clinical utility of the Prati criteria and normal ALT (<40？IU/L) in a cohort of patients with chronic hepatitis B infection (CHB). Methods. Serology, radiology, and histology were obtained in 140 patients with CHB. Results. HBeAg+ group: 7 patients (7/56？12% HBeAg+ group) misclassified as “immunotolerant”, with HBV DNA > 6 log copies/ml and normal ALT, who in fact had moderate/severe fibrosis on liver biopsy. HBeAg？ group: 10 patients with normal ALT and moderate/severe fibrosis on liver biopsy; 4 of these patients had >3 log copies/ml HBV DNA levels and 6 patients misclassified as “inactive carriers” with negative HBV DNA levels normal ALT and moderate/severe fibrosis (6/84？7% HBeAg？ group). Two male HBeAg+ and three male HBeAg- patients with ALT between 20 and 30 IU/L and moderate/severe fibrosis on liver biopsy would have been further mischaracterised using the Prati criteria for normal ALT. Age and ethnic group were more important predictors of moderate/severe fibrosis in multivariate analysis. Conclusion. HBeAg status, age, ethnic origin with longitudinal assessment of LFTs and viral load should be studied in patients with “normal ALT” at the upper end of normal range (ALT 20–40 IU/L) to appropriately classify patients and identify patients for liver fibrosis assessment to inform treatment decisions. 1. Introduction An estimated 400 million people worldwide have chronic hepatitis B virus infection, of whom 1 million people will die each year from its complications [1, 2]. In the United Kingdom, it is estimated that over 180,000 people are infected, with the numbers increasing rapidly (http://www.hepb.org.uk/). In general, patients with chronic hepatitis B infection have historically been stratified into 4 classic categories according to the natural history of the infection [2, 3].(1)Immune-tolerant phase: HBeAg positive with high levels of viral replication (HBV DNA levels: >6 log), normal ALT, without necroinflammation in the liver and a low risk of progression to cirrhosis. (2)Immune-active phase: HBeAg positive with high levels of viral replication (HBV DNA levels: >6 log), increased ALT, necroinflammation in the liver with a high risk of progression to cirrhosis.(3)Inactive HBV carrier state: these patients have undergone seroconversion to anti-HBe status. It is characterised by very low/undetectable HBV DNA levels, normal ALT, without necroinflammation on liver histology and low risk of progression to cirrhosis. (4)HBeAg-negative chronic hepatitis B infection (precore/basal core mutant disease) the development of
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