Serum biomarkers combine to improve HCC risk stratification in HBV patients with low viremia
medwireNews: In patients with persistently low serum levels of hepatitis B virus (HBV) DNA, the combined use of the noninvasive aspartate aminotransferase to platelet ratio index (APRI) and the Fibrosis-4 (FIB-4) index could help identify those at increased risk for developing hepatocellular carcinoma (HCC).
The chart review included 1006 patients with chronic HBV who had low-level viremia, defined as HBV DNA levels below 2000 IU/mL in two consecutive assessments during the year prior to enrolment.
Over a median 5.1 years of follow-up, 36 patients developed HCC, and although the incidence was higher in the 139 patients with cirrhosis, as detected by ultrasonography, at 13.7%, HCC did develop in 2.0% of the 867 noncirrhotic patients.
Combining the APRI and FIB-4 indices, both of which rely on easily obtained parameters, enabled the HCC risk in this population of patients with low-level viremia to be “effectively stratified,” reports the team from Sungkyunkwan University School of Medicine in Seoul, South Korea.
Specifically, the 5-year cumulative incidence of HCC was 13.9% for the group of patients with high APRI and FIB-4 scores, that is, at or above the respective cutoffs of 0.50 and 1.45 points. This was significantly higher than the 1.4% rate observed for the group with a high score on any one test and the 1.2% rate for those with low scores on both tests (p<0.001).
The combined use of the APRI and FIB-4 tests also stratified noncirrhotic patients according to their HCC risk, such that the cumulative incidence at 5 years was 11.4% for those with high scores on both tests, compared with 1.5% and 0.4% for those with a high score on any test or low scores on both tests, respectively, a significant difference (p<0.001).
But using the tests together did not further stratify the HCC risk for patients with cirrhosis, according to the article published in Liver International.
Time-dependent area under the receiver operating characteristic curve analysis showed that the combined use of APRI and FIB-4 correctly identified patients likely to develop HCC over a 5-year period on 78% of occasions, whereas the corresponding values for each test alone were 76% and 71%. The researchers point out, however, that the combined test had a significantly better predictive ability only when compared with the FIB-4 test (p<0.001).
They propose an algorithm whereby chronic HBV patients with low-level viremia who show evidence of cirrhosis on ultrasonography should be managed as compensated cirrhotic patients and started on antiviral therapy as per international guidelines. For those without evidence of cirrhosis, the APRI plus FIB-4 scores should be used to determine whether they would benefit from further evaluation by transient elastography or liver biopsy (ie, if either score is high) or whether they can undergo monitoring (ie, both scores are low).
Dong Hyun Sinn and co-researchers conclude: “Although more data are needed, this can be [a] cost-effective approach, as APRI and FIB-4 are simple markers without additional cost.”
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