tp du fibrosis biomarkers

16 janv. 2009

LiverCenter

Biomarkers in a World without Gold Standards

Thierry Poynard

AP-HP Groupe Hospitalier Pitié Salpêtrière,UPMC Liver Center, Université Paris 6,

CNRS UMR 8149, Université Paris 5, Biopredictive France

16 janv. 2009

TexteJanuary 2009

16 janv. 2009

3

Validated Fibrosis Biomarkers 350.000 in 35 countries

FibroTest ActiTest

16 janv. 2009

F0

Pas de Fibrose

16 janv. 2009

F1

Fibrose minime

16 janv. 2009

F2

Fibrose modérée

16 janv. 2009

F3

Fibrose importante

16 janv. 2009

F4

Fibrose sévère

16 janv. 2009

Top 10 FAQ

• Are the authors credible due to their possible conflict of interest?

• Is the perfect fibrosis biomarker possible?

• Are there a specific "gray zone" or "inaccurate zone" between intermediate stages?

• Is the methodological quality of patented biomarkers better than non-patented biomarker?

• Is the liver biopsy still useful?

• What are the normal values of a fibrosis marker?

• What is the diagnostic value of Fibrotest according to liver disease?

• What is the prognostic value of FibroTest vs biopsy ?

16 janv. 2009

Biomarkers in Chronic Liver Disease

• New methodology

• Hepatitis B

• Hepatitis C

• Global screening

16 janv. 2009

Message I: Appropriate methods

• Imperfect Gold Standard

• Spectrum bias

• Analysis of discordances

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008

16 janv. 2009

Message II: Appropriate markers

• Hepatologist: Must

• GP and Screening: Simple

• Industry: Rapid

• Health Authorities: Surrogate Endpoint

16 janv. 2009

Fibrosis estimates: Profile A

• “Biopsy is still the gold standard”

• “Biomarkers on the market are not accurate enough”

• “I steel need biopsy for all my patients”

• “Biomarkers only if contra-indications of liver biopsy”

Biopsy Biomarker

16 janv. 2009

N Engl J Med 2001

16 janv. 2009

Risk of chronic liver disease

Biopsy

If contra-indicationBiomarker

16 janv. 2009

Fibrosis estimates: Profile B

• “Too many false positive/false negative for intermediate stages”, “Gray zone”

• “Ok for the next generation of biomarkers when they will demonstrate 90% AUROCs for bridging fibrosis (F2)”

• “Ok for cirrhosis biomarkers or elastography, as AUROCs = 90%”

Biopsy Biomarker

16 janv. 2009

16 janv. 2009

Fibrosis estimates: Profile C

• “Still risk of severe adverse events for liver biopsy”

• “Biopsy has same limitations for adjacent stages than validated biomarkers: there is no intermediate gray zone”

• “No rational or evidence based for biopsy as first line test”

• “Biopsy still necessary if biomarkers results at high risk of false positive/negative”

Biopsy Biomarker

16 janv. 2009

Chronic Hepatitis B or C

FibroTest ActiTest

Advanced FibrosisSevere Activity

Hepatologist

Fibroscan if FibroTest not applicable

No Advanced FibrosisNo Severe Activity

FibroTest every 2-4 years

16 janv. 2009

10 years of claims for diagnostic procedures 1993-2003: Severe Adverse Events and Deaths (French Insurance)

Technic Severe Adverse Events Deaths

ERCP 71 30

Liver Biopsy* 11 5

Ultrasound-Endoscopy 4 2

*1 death /8,000 biopsies if one claim out of 2 deaths

Standard severe adverse events prevalence: 3/1,000

Poynard T. Rev Med Interne 2007

16 janv. 2009

16 janv. 2009

Bedossa Hepatology 2003

AUROC 5 mm = 0.75AUROC 15 mm = 0.82AUROC 25 mm = 0.89

“We showed that with 25-mm long biopsy specimens, only 75% were scored correctly and 65% for 15-

mm biopsy specimens”

16 janv. 2009

Parkes et al review, J Hepatol 2006: An illustration of obsolete methodology using imperfect gold standard as a perfect gold standard

• If the Parkes et al statements and conclusions were applied to 25 mm liver biopsy, which only scored correctly in 75% using perfect gold standard:

• “The 25 mm liver biopsy have a place in assessment of fibrosis to rule-in or rule-out fibrosis, but in individual patients cannot differentiate the stages of fibrosis reliably. “

16 janv. 2009

Poynard et al APT 2007

16 janv. 2009

Summary

• Biopsy has also a “Gray zone” for adjacent stages. To discriminate between F1 and F2 (one stage difference) is more difficult than to discriminate between F01 vs F234, and between F0123 vs F4

• Don’t mix “adjacent” stages (F1 vs F2 or F3 vs F4) and “intermediate” stages (F1, F2, F3 vs F0, F4)

• Standardization of AUROCs according to prevalence of stages defining non-advanced or advanced fibrosis (0.67-0.98)

• Standardization of AUROCs according to biopsy length

Bedossa Hepatology 2003, Poynard Clin Chem 2007, Poynard APT 2007

16 janv. 2009

Imperfect Gold Standard: Summary

• Entire liver is the perfect Gold Standard

• Biopsy is an imperfect Gold Standard

• Biopsy 25 mm has 25% false positive/ negative versus entire liver

• Waiting for 90% AUROCs for bridging fibrosis biomarker is a dream in a world without Gold Standards

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008

16 janv. 2009

Message I: Appropriate methods

• Imperfect Gold Standard

• Spectrum bias

• Analysis of discordances

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008

16 janv. 2009

Spectrum bias: examples

• Relative accuracy of FibroTest for the diagnosis of fibrosis stages

• FibroTest in White vs non-White HBV patients

• FibroTest in HCV patients with normal ALT

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008

16 janv. 2009

Biomarkers in Chronic Liver Disease

• New methodology

• Hepatitis B

• Hepatitis C

• Global screening

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008

16 janv. 2009

• 38 Published Studies

• 7.985 Patients

• Standardized AUROC

• 0.84 (0.83-0.86)

• Advanced Fibrosis

Friedrich Rust et al Gastroenterology 2008, Halfon et al GCB 2008

The best you can obtain with

20mm biopsy is 0.90 Bedossa 2003

FibroTest

16 janv. 2009

FibroTest in Chronic Hepatitis B: 3,303 patients

• Myers, J Hepatol 2003 n=209

• Poynard, Am J Gastro 2005 n=283

• Cales, Hepatology 2005 n=46

• Sebastiani, World J Gastro 2006 n=110

• Coco, JVH 2007 n=93

• Zhao Chines J Pract Int Med 2007 n=123

• Poynard, JVH 2008 n=924

• Ngo, 2008 PlosONE 2008 n=1,300

• Abstracts: Castera, J Hepatol 2006 n=154; Hilleret, J Hepatol 2006 n=184,

16 janv. 2009

Adefovir, 2 Registrational Trials: Results using FibroTest-ActiTest (Poynard JVH 2008)

• 462 patients included 304 Adefovir and 158 Placebo:

• Paired biopsy and FibroTest

• 924 estimates of liver injury

• F0 n=21

• F1 n=596

• F2 n=160

• F3 n=69

• F4 n=78

F49%F3

3%

F218%

F168%

F02%

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Fibrotest and Fibrosis Stages

Poynard JVH 2008

16 janv. 2009

ActiTest and Necro-Inflammatory features

Poynard JVH 2008

16 janv. 2009

ActiTest and Necro-Inflammatory Scoring System

Poynard JVH 2008

16 janv. 2009

0

0,75

1,50

2,25

3,00

Adefovir Biopsy Placebo Biopsy

Baseline48 weeks

Impact of HBV treatment on fibrosis (Biopsy) in HBV patientsVirological Responders with advanced baseline fibrosis

97 treated with adefovir, 9 treated with placebo (spontaneous clearance)

P<0.0001

Poynard JVH 2008

16 janv. 2009

0

0,35

0,70

Adefovir FibroTest Placebo FibroTest

Baseline48 weeks

P<0.0001 P=0.02

Impact of HBV treatment on fibrosis (FibroTest) in HBV patientsVirological Responders with advanced baseline fibrosis

97 treated with adefovir, 9 treated with placebo (spontaneous clearance)

Poynard JVH 2008

16 janv. 2009

Discordance Analysis in HBV patients

• The ratio between the number of discordant cases attributable to a biopsy failure and to FT-AT failure in this subpopulation of patients with incoherence between virological and histological response (worsening fibrosis with virological response)

• Could be considered as an estimate of the overall ratio in the general population including patients without incoherence

Poynard JVH 2008

39

16 janv. 2009

Discordance Analyses in HBV

• 29% discordances of FibroTest estimated by the classical analysis considering biopsy as the gold standard

• New method using discordant cases with incoherence between virological response and histological response (n=29)

• Failure attributable to biopsy 66% (19/29) false positive median 11mm, false negative median 7-mm

• Failure attributable to FT-AT 34% (10/29)

• If these estimates are true the real rates of patients misclassified using FT-AT is 10% (34% of 29%)

Poynard JVH 2008

40

16 janv. 2009Kinetics of fibrosis according to baseline stagesIn HBV patients treated with lamivudine 2 years

n=283

F0F1 NS

F2F3F4 P=0.01

0.00

0.25

0.50

0.75

1.00

Baseline 6 mo 12 mo 24 mo

FibroTest-FibroSURE

44 Cirrhosis: 42 (95%) improvement at 24 months; Significant regression (>0.30) in 14/44 (32%)

0.73

0.52

Dienstag et al Gastroenterol 2003. Poynard et al Am J G 2005

16 janv. 2009

HBV Survival according to FibroTest classes n= 1,300

FibroTest METAVIR

0.59-1.00 F3-F4

0.32-0.58 F1-F2, F2

0.00-0.31 F0-F1

Ngo PlosONE 2008

16 janv. 2009

This definition had a 100% negative predictive value for liver related complications or death. Classical definition of inactive carrier with normal transaminases, 23% had presumed fibrosis, and 3 complications occurred during the follow-up.

Ngo PlosONE 2008

16 janv. 2009

A New simple definition of HBV Inactive Carrier

FibroTest<= 0.27 ActiTest <= 0.29

+

Ngo PlosONE 2008

Viral Load < Log5

16 janv. 2009

Summary:FibroTest-ActiTest in patients with chronic hepatitis B

• Similar accuracy than in HCV, validated at baseline, during and after HBV treatment

• Discordances are also due to biopsy failure in at least 50% of cases

• More sensitive than biopsy

• Same prognostic value than biopsy

• Permitted a better definition of non active carrier

45

16 janv. 2009

Biomarkers in Chronic Liver Disease

• New methodology

• Hepatitis B

• Hepatitis C

• Global screening

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007

46

16 janv. 2009

• 38 Published Studies

• 7.985 Patients

• Standardized AUROC

• 0.84 (0.83-0.86)

• Advanced Fibrosis

•

Friedrich Rust et al Gastroenterology 2008, Poynard et al SJG 2008

FibroTest

The best you can obtain with

20mm biopsy is 0.90 Bedossa 2003

47

Elastography

16 janv. 2009

FibroTest: from blood donors to cirrhotics (n=1,570)

0.00

0.33

0.67

1.00

F0 F1 F2 F3 F4

Fibr

otes

t

BloodDonors

16 janv. 2009

FibroTest Diagnostic Values: Stage by Stage Analysisn=1570 Poynard, Comp Hepatol 2004; n=506 Halfon AJG 2006Same diagnostic value for low, intermediate or elevated stages

BDvsF0 F0vsF1 F1vsF2 F2vsF3 F3vsF4

0

0,25

0,50

0,75

1,00

AUROC

16 janv. 2009

AUROC Standardization of FibroTest

• Regression line permitted to calculate FT AUROC according to differences observed between mean fibrosis of advanced fibrosis group and that of non-advanced fibrosis group (DANA):

• AUROC = 0.582 + 0.105 x (DANA)

• For a standardized population with equal prevalence of each 5 fibrosis stages of 20% and DANA = 2.5

• standardized FibroTest AUROC = 0.85

• Idem for a naturalistic prevalence of each stage

Poynard Clin Chem 2007

50

16 janv. 2009

F2 vs F1

DANA = 1

AUROC = 0.67

F2,4 vs F0,8

DANA = 1,6

AUROC = 0.70

Sebastiani JVH 2008. Poynard JVH 2008

16 janv. 2009

FibroTest AUROCs for the diagnosis of Advanced Fibrosisin patients with elevated or normal ALT

0

0,3

0,6

0,9

Observed Standardized

P=0.02 NS

Sebastiani JVH 2008, Poynard JVH 2008, Poynard BMC Gastroenterol 2007

Elevated ALT Normal ALT

0

0,3

0,6

0,9

Standardized

n=1833 n=493n=164 n=80 n=164 n=80

NS

16 janv. 2009

Analyses of Discordances

• Failures of biopsy

• Failures of biomarkers

• Failures of elastography

Reguev AJG 2003, Poynard Clin Chem 2004, Poynard APT 2007, Coco JVH 2007

54

16 janv. 2009

537 Prospective Cases Same day Biopsy and FibroTestCause of errors in the 154 (29%) cases with discordant results

2% FT-AT vs 18% Biopsy (p<0.001)

Poynard et al, Clin Chem 2004

55

16 janv. 2009

Bedossa et al, Hepatology 2003

Poynard et al, Clin Chem 2004 Quality of Liver Biopsy:

Pitie experience 1,773 biopsies: 16% > 25mm Median 15 mm

16 janv. 2009

Prognostic value

• FibroTest in HCV: Ngo, Clin Chem 2006

• FibroTest in HBV: Ngo, PlosOne 2008

• FibroTest in ALD: Naveau, Hepatology 2008

• FibroTest in Mixed severe cirrhosis: Thabut, AASLD 2007

57

16 janv. 2009

Security Algorithms: Apparently healthy Blood donors

952 Blood Donors

Security Algorithms

29 High Risk Profile (3%)False Positive/Negative

9 HR Gilbert (0.9%)4 HR Hemolysis (0.4%)

925 97% TestsEasy to Interpret

No F2F3F4

Poynard 2004, Imbert Bismut 2004

16 janv. 2009

FibroTest validation in “difficult to diagnose patients”

• HIV-HCV: Myers 2003, Cacoub 2008

• Aged patients: Thabut 2006

• Children: de Ledinghen 2007, Friedrich 2008

• Renal insufficiency: Varaud 2005

• Vasculitis: Cacoub 2006

• Hemophiliac Mahor 2006

• Transplanted

• Kidney: Varaud 2006

• Liver: Hamelet 2008

• Normal ALT Poynard 2006, 2008, Castera 2006

59

16 janv. 2009

Relapse/Reject n=8

No Relapse/Reject n=15

P<0.001

Before LT 24-72 h 7 days 2 weeks 4 weeks 24 weeks 48 weeks

FibroTest in the follow-up of liver transplanted patients: a pilot study

Hamelet EASL 2008

16 janv. 2009

FibroTest before and after HCV Treatment Estimates 72 weeks Anti-Fibrotic Impact

0

0,2

0,4

0,6

0,8

F01 NR n=58 F01 SVR n=119 F234 NR n=110 F234 SVR n=65

Baseline EOF

-26%

-31%

Poynard et al Hepatology, 200361

16 janv. 2009

FibroTest ActiTestEstimates of 72 wks anti-fibrotic and anti-activity impact in 22 SVR PEG-Riba

0

0,2

0,4

0,6

0,8

FibroTest ActiTest

Baseline W12 W24 W48 EOF

D’Arondel et al JVH, 2006

-28%

-75%

62

16 janv. 2009

16 janv. 2009

TestNbStudies

NbPatients

Quality Score

FibroTest 33 6,549 60/62

FibroSpect 4 463 30/62

FibroMeter 2 1,041 26/62

ELF 3 1,134 30/62

HepaScore 3 757 25/62

Poynard et al, Advances in Clinical Chemistry, 2008, GCB 2008

Quality of Patented Liver Biomarkers

16 janv. 2009

Fibrotest has better diagnostic and prognostic value than APRI in patients with chronic hepatitis C. Morra R et al. Hepatology 2008

16 janv. 2009

Association of marker with clinical endpoint

• Example for FibroTest in 537 HCV patients with 29 liver complications 5 yr**

* Chakravarty FDA 2008, **Ngo et al Clin Chem 2007

Se Sp Relative RiskAttributable Proportion

FibroTest >0.58

0.97 0.75 68 0.98

Biopsy F4 0.60 0.93 11 0.65

66

16 janv. 2009

• 11 Published studies

• n=2,260

• Standardized AUROC

• Advanced Fibrosis

• 0.89 (0.84-0.95)

Friedrich Rust et al Gastroenterology 2008, Poynard et al SJG 2008

67

Elastography

16 janv. 2009

Kettaneh et al. J Hepatol 2005

FibroTest vs FibroScan

68

16 janv. 2009

Choice of FibroScan Cutoffs

Castera 2005, Ketanneh 2007Roulot 2008

For F2: 7.1 or 8.8 kPa ? FibroScan false negatives ?Low negative predictive value

For F4: 12.5 or 14.5 kPa ?

For F0: 7.1 kPa 12.6% false positives ? 8.8 kPa 3.6% false positives ?

For screening 7.1 kPa ?

For patients 8.8 kPa ?

No rationale for changing cutoff according to liver disease

F2 8.8 kPa F4 14.5 kPa

F4 0.73

F2 0.48

Poynard PlosOne 2008

16 janv. 2009

Poynard PlosOne 2008

FibroTest!First Line!

Reference Center FibroScan for!Confirmation !

Biopsy!If discordances!

16 janv. 2009

Summary:FibroTest-ActiTest in patients with chronic hepatitis C

• Most validated Biomarker, approved by health authorities

• Validated at baseline, during and after HCV treatment

• Validated in difficult to diagnose patients

• Discordances due to biopsy failure in at least 50% of cases

• More sensitive than biopsy ?

• Better prognostic value than biopsy ?

72

16 janv. 2009

Biomarkers in Chronic Liver Disease

• New methodology

• Hepatitis B

• Hepatitis C

• Global screening

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007

73

16 janv. 2009

FibroMAX: HCV-HBV-ALD-NAFLD

ActiTest

FibroTest SteatoTest

AshTest

NashTest

FibroMAX

74

16 janv. 2009

SteatoTest for Steatosis744 patients 140 controls

SteatoTestGGT AUROC=0.66

ALT AUROC=0.61

AUROC=0.80

Poynard Comp Hepatol 2005

Insulin Resistance Diabetes 2 Obesity HyperlipidemiaArterial Hypertension

FibroTest SteatoTest NashTest

Advanced FibrosisOr NASH

No FibrosisNo NASH

Hepatologist FibroMAXEvery 2-4 years

Fibroscan if FT non

applicable

Heavy Drinker

FibroTest SteatoTestAshTest

Advanced FibrosisOr Steato-Hepatitis

No FibrosisNo Steato-Hepatitis

Hepatologist FibroMAXEvery 2 years

Fibroscan if FT non

applicable

16 janv. 2009

New concept in liver diseases

• Biomarkers are for Hepatologists

• the HDL-Cholesterol for Cardiologists

• Using biomarkers validated for the frequent chronic liver diseases,

• GP will screen advanced fibrosis for Hepatologists,

• Who have good treatment, at least for HCV and HBV

78

16 janv. 2009

Insulin resistance

Alcool consumption

Hepatitis B

Hepatitis C

Hemochromatosis

0 150 300 450 600

No advanced fibrosis Advanced fibrosis

79

Population at risk of liver fibrosis, cirrhosis and hepatocellular carcinoma (Millions)

F4

F1

F0

France: 12,000,000 at Risk100%

5%

Death 15,000/year0.1%

FibroTest10% F2

F3

16 janv. 2009

Presumed Liver Injury assessed by FibroMAX in 1909 Hyperlipidemic patients according to the number of metabolic factors

0

25

50

75

100

Steatosis SteatoHepatitis Fibrosis

0 1 2 3 4 5

Ratziu et al APT 2006

81

16 janv. 2009

Presumed Liver Fibrosis assessed by FibroTest in 1909 Hyperlipidemic patients according to the number of metabolic factors

0

2,5

5,0

7,5

10,0

0 1 2 3 4 5

Ratziu et al APT 2006

82

16 janv. 2009

Prospective screening of liver fibrosis using FibroTest in 1.131 naive diabetic patients

Jacqueminet et al CGH 2008

74 Excluded20 by security algorithms

50 duplicates4 not diabetics

21 not presumedAdvanced fibrosis

3 not reinvestigated

32 Confirmed fibrosis20 Cirrhosis

8 Many septa4 Few septa

32 reinvestigated

35 presumedAdvanced Fibrosis

56 with previous historyof liver disease

1068 not presumedAdvanced fibrosis

18 not reinvestigated

32 Confirmed fibrosis5 Cirrhosis (4 liver cancer)

10 Many septa17 Few septa

13 Unconfirmed4 False positive FibroTest

9 not classified

45 reinvestigated

63 presumedAdvanced Fibrosis

1131 without previous historyof liver disease

1187 Diabetics included

1261 Diabetics preincluded

16 janv. 2009

Prevalence of presumed fibrosis

Prevalence of liver disease among advanced fibrosis

Prospective screening of liver fibrosis using FibroTest in 7.500 subjects of a general population

84

Reduce death due to cirrhosis by 50%