lmo Laboratory Medicine Online Lab Med Online ∗∗ 2093-6338 The Korean Society for Laboratory Medicine 10.3343/lmo.2019.9.3.153 lmo-9-153 Original Article Evaluation of Noninvasive Liver Fibrosis Blood Markers in Patients with Chronic Hepatitis B and Hepatitis C LeeJong-HanM.D. ChoJooyoungM.D. KimJuwonM.D. UhYoungM.D. YounKap JunM.D. Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Corresponding author: Jong-Han Lee, M.D., Ph.D. https://orcid.org/0000-0003-4036-8443 Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea Tel: +82-33-741-1594, Fax: +82-33-731-0506, E-mail: cello425@yonsei.ac.kr 07 2019 20 07 2019 9 3 153 160 28092018 09112018 13122018 Copyright © 2019 The Korean Society for Laboratory Medicine 2019 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background

Liver fibrosis evaluation is an important issue in chronic liver disease patients. We aimed to develop noninvasive liver fibrosis biomarkers based on transient elastography (TE, FibroScan®) through retrospective review of clinicopathological data.

 Methods

We recruited 278 chronic hepatitis B patients who underwent Fibroscan and HBV DNA testing. A total of 115 HBeAg-positive and 159 HBeAg-negative chronic hepatitis B patients were analyzed. A total of 100 hepatitis C patients were analyzed. Successful fibroscan data, gamma-glutamyl transferase (GGT) to platelet ratio (GPR), platelet count, AST, ALT, international normalized ratio of prothrombin time, total cholesterol, triglycerides, bilirubin, mean platelet volume, AST to platelet ratio index, fibrosis index based on four factors (FIB-4), neutrophil to lymphocyte ratio (NLR), and NLR to platelet ratio were analyzed to determine the new noninvasive markers for assessing liver fibrosis.

 Results

Elevated GPR (OR=9.1, P=0.011) and FIB-4 (OR=2.3, P=0.01) were associated with greater risk of liver fibrosis in chronic hepatitis B patients. FIB-4 (OR =6.04, P=0.005) was a risk factor for liver fibrosis in HBeAg-positive patients. FIB-4 (OR =2.371, P=0.015) and GPR (OR=33.78, P=0.003) were liver fibrosis risk factor in HBeAg-negative patients. In chronic hepatitis C patients, GGT (OR=1.033, P=0.002), triglyceride (OR=–0.990, P=0.038) and FIB-4 (OR=3.499, P=0.006) showed statistical significances. The AUCs were 0.816 in FIB-4 (P<0.001) and 0.849 in GPR (P<0.001).

 Conclusions

FIB-4 and GPR may be useful blood markers for assessing liver fibrosis in chronic hepatitis B and hepatitis C patients. Further well-designed prospective study is required to validate these noninvasive blood markers in clinical practice.

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Box plot of gamma glutamyl transferase (GGT), platelet count, FIB-4 and GPR in chronic hepatitis B patients.

Receiver operating characteristic (ROC) curve analysis of FIB-4 and GPR for the evaluation of liver fibrosis comparing transient elastography (fibroscan) results in chronic hepatitis B patients.

Summary of calculated biomarkers for liver fibrosis expectation

Calculated biomarkers Calculation formula
APRI [100×AST (U/L)/ULN (40 (U/L) for male, 35 (U/L) for female/platelet count (109/L)]
FIB-4 age×AST (U/L)/platelet count×ALT1/2
GPR [100×GGT (U/L)/ULN (60 (U/L) for male, 40 (U/L) for female)/platelet count (109/L)]
NLR Neutrophil/lymphocyte
NLR to platelet count Neutrophil/lymphocyte/platelet count

Abbreviations: APRI, AST to platelet ratio index; ULN, upper limit of normal; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; GGT, gamma-glutamyl transferase; NLR, neutrophil to lymphocyte ratio.

Levels of parameters according to different liver stiffness measurement levels measured by transient elastography

Scale of liver stiffness measurement (kPa) <5.3 kPa 5.3–<7.2 kPa 7.2–<9.4 kPa 9.4–<12.2 kPa ≥12.2 kPa
Number 60 54 38 34 92
Age 44±12.9 (20–81) 46.8±11.1 (19–73) 46.7±12 (25–78) 46.9±9.7 (29–66) 49.5±10.4 (15–81)
Gender ratio (Male/Female) 1.3 (34/26) 1.7 (34/20) 1.1 (20/18) 1.3 (19/15) 3 (69/23)
HBeAg (Positive/Negative) 0.3 (13/47) 0.6 (20/34) 0.5 (13/25) 0.9 (16/18) 1.4 (54/38)
Liver stiffness measurement (kPa) 4±0.69 (2.4–5.2) 6.03±0.54 (5.3–7.1) 8.14±0.67 (7.2–9.3) 10.72±0.87 (9.4–12) 24.92±12.82 (12.2–72)
Inter quartile range 0.57±0.25 (0.1–1.1) 0.76±0.33 (0.1–1.6) 1.06±0.4 (0.3–2) 1.31±0.58 (0.3–2.7) 2.74±1.73 (0–10.7)
Success rate (%) 93.4±11 (60–100) 96.6±7.6 (71–100) 97.5±8.14 (63–100) 98.6±4.3 (80–100) 96.6±7.6 (67–100)
Platelet (×109/L) 230.9±51.3 (128–358) 197.8±59.1 (66–321) 194.3±81.6 (62–547) 188.7±63 (77–339) 128.5±55.4 (44–395)
GGT (U/L) 28±26.4 (6–146) 38.6±32.7 (9–153) 58.4±82.3 (7–525) 71±49.6 (8–203) 114±115.4 (15–809)
Cholesterol (mg/dL) 180.6±30.1 (118–253) 177.2±35.4 (91–280) 172.9±37.3 (120–318) 174.2±28.4 (124–236) 159.7±32.6 (88–235)
AST (U/L) 30.3±32.6 (12–265) 33.6±19 (17–135) 58.1±50.1 (20–242) 57.4±40.9 (18–178) 147.1±283.8 (19–2255)
ALT (U/L) 40.4±93 (8–738) 40.7±36.8 (6–229) 81.1±96.4 (10–445) 69±71.9 (11–304) 198.2±473.5 (12–3690)
INR (sec) 1.01±0.06 (0.86–1.16) 1.02±0.06 (0.9–1.16) 1.06±0.12 (0.92–1.7) 1.05±0.05 (0.96–1.16) 1.16±0.19 (0.91–2.52)
Bilirubin (mg/dL) 0.74±0.33 (0.17–1.7) 0.83±0.42 (0.3–2.22) 0.74±0.35 (0.3–1.8) 0.69±0.33 (0.2–1.52) 1.45±2.11 (0.3–14.41)
HBVDNA (IU/mL) 2,501,759±9,852,121.6 (22–61,300,000) 7,517,113.8±29,539,919.9 (24–170,000,000) 16,979,600.8±45,423,067 (36–170,000,000) 11,900,288.5±40,473,294.1 (23–170,000,000) 9,871,502.5±20,958,659.1 (37–132,000,000)
Triglyceride (mg/dL) 104.3±53.2 (29–277) 99.3±49.8 (42–239) 84.8±37.8 (32–198) 93.7±29.7 (46–169) 94.3±43 (28–282)
MPV (fL) 7.918±0.748 (6.4–10) 7.989±0.715 (6.2–9.4) 8.113±0.767 (6.3–9.9) 8.147±0.827 (6.4–10.5) 8.762±0.882 (7–11.2)
Neutrophil (%) 55.9±8.5 (38.1–74.9) 53.3±8.2 (37.7–68.1) 52.5±8.7 (36.3–71.3) 50.9±10.6 (31.9–74.6) 52.3±10.5 (27.5–80.5)
Lymphocyte (%) 34±7.2 (18.6–49.8) 36±7.7 (19.6–50.6) 36.8±7.6 (19.8–52.8) 38.2±10.1 (16.8–56.8) 35.2±9.6 (11.8–59.5)
AST/ALT 1.04±0.42 (0.36–2.5) 1.04±0.47 (0.45–3.17) 1.02±0.65 (0.44–4) 1.08±0.59 (0.48–3.14) 1.14±0.72 (0.37–4.08)
APRI 0.37±0.398 (0.096–3.125) 0.498±0.394 (0.169–2.836) 0.913±0.902 (0.274–4.327) 0.873±0.624 (0.174–2.565) 3.348±7.101 (0.181–53.184)
FIB-4 1.063±0.573 (0.266–2.591) 1.539±1.019 (0.379–5.756) 2.022±1.807 (0.527–8.89) 2.023±1.127 (0.4–5.833) 4.657±3.961 (0.736–27.084)
GPR 0.251±0.266 (0.059–1.83) 0.43±0.485 (0.08–2.47) 0.689±0.889 (0.065–5.435) 0.821±0.655 (0.051–3.076) 1.878±2.225 (0.095–16.245)
NLR 1.778±0.665 (0.765–4.027) 1.604±0.604 (0.751–3.474) 1.549±0.633 (0.688–3.601) 1.534±0.841 (0.562–4.44) 1.716±0.954 (0.476–6.822)
NLR/platelet 0.008±0.004 (0.003–0.02) 0.009±0.006 (0.003–0.044) 0.009±0.005 (0.003–0.025) 0.01±0.009 (0.002–0.039) 0.016±0.012 (0.002–0.071)

Abbreviations: GGT, gamma-glutamyl transferase; AST, aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio of prothrombin time; MPV, mean platelet volume; APRI, AST to platelet rati index; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio.

Diagnostic sensitivity, specificity, positive predictive value and negative predictive value of FIB-4 and GPR for liver fibrosis prediction

Parameters Sensitivity (%) Specificity (%) PPV (%) NPV (%) AUC P value
FIB-4 (cut-off: 1.571) 65.1 86.7 86.7 86.7 0.82 <0.001
GPR (cut-off: 0.299) 79.4 83.3 83.3 83.3 0.84 <0.001

Abbreviations: FIB-4, fibrosis index based on four factors; PPV, positive predictive value; NPV, negative predictive value; GPR, gamma-glutamyl transferase to platelet ratio; AUC, area under the curve.

Characteristics of baseline parameters according to HBeAg status

  HBeAg positive (N=115) HBeAg negative (N=159) P value
Age (yr) 45.4±11.9 48.3±10.9 0.037
Sex ratio (Male:Female) 1.7 (73:42) 1.7 (100:59) 0.921∗
Liver stiffness measurement (kPa) 14.751±11.156 10.757±10.683 0.003
AST (U/L) 95.8±142.3 63±193 0.124
ALT (U/L) 132.5±268 80.5±302.5 0.142
GGT (U/L) 68.3±58.2 63.7±94.2 0.644
Total Bilirubin (mg/dL) 0.9±0.55 1.05±1.63 0.344
Total Cholesterol (mg/dL) 170.5±30.8 172.1±35.4 0.696
Triglyceride (mg/dL) 94.5±41.9 97.4±47.5 0.605
Platelet count (×109/L) 174.1±73.6 186.4±70.1 0.163
Mean platelet volume (fL) 8.41±0.86 8.17±0.88 0.022
Prothrombin time, INR 1.09±0.12 1.07±0.16 0.265
HBV DNA (IU/mL) 21,028,204.8±41,665,244.9 591,105.9±3,276,928.3 <0.001
AST/ALT ratio 1.11±0.71 1.04±0.46 0.282
APRI 1.747±2.596 1.345±5.241 0.449
FIB-4 2.958±2.799 2.275±2.879 0.05
GPR 0.9±0.813 0.922±1.777 0.889
NLR 1.53±0.704 1.753±0.829 0.02
NLR/platelet count 0.011±0.008 0.012±0.01 0.309

Pearson's chi-square test. Statistical significant P values were printed in bold.

Abbreviations: AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma-glutamyl transpeptidase; INR, international normalized ratio of prothrombin time; APRI, AST to platelet ratio index; FIB-4, fibrosis index based on the four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio.

Levels of parameters according to liver stiffness measurement in chronic HCV infected patients

  LSM<5.3 kPa (N=74) LSM≥5.3 kPa (N=26) P value
Genotype 1b/2a 37/37 17/9 0.176∗
Age (yr) 53 58 0.016
Male/Female 37/37 11/15 0.499∗
LSM (kPa) 4.05 10.3 <0.001
AST (U/L) 36 65 <0.001
ALT (U/L) 44.5 82 0.001
GGT (U/L) 27.5 83.5 <0.001
Bilirubin (mg/dL) 0.58 0.705 0.010
Cholesterol (mg/dL) 191.5 160.5 0.001
Triglyceride (mg/dL) 117.5 98 0.004
Platelet (×109/L) 237.5 173.5 <0.001
MPV (fL) 7.25 7.9 0.004
INR (sec) 0.985 1.025 0.005
HCV RNA 834,000 1,510,000 0.535
AST to ALT ratio 0.86 0.845 0.786
APRI 0.405 1.005 <0.001
FIB-4 1.245 2.78 <0.001
GPR 0.12 0.475 <0.001
NLR 1.755 1.45 0.210
NLR/platelet 0.007 0.008 0.049

Pearson's chi-square test.

Abbreviations: GGT, gamma-glutamyl transferase; MPV, mean platelet volume; INR, international normalized ratio of prothrombin time; APRI, AST to platelet ratio index; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio.