Michel BEAUGRANDMichel BEAUGRAND

EVALUATION OF LIVER FIBROSISEVALUATION OF LIVER FIBROSISBLOOD TESTS, LIVER BIOPSY AND BLOOD TESTS, LIVER BIOPSY AND

FIBROSCANFIBROSCAN

M. BeaugrandM. Beaugrand

Service d’HépatologieService d’Hépatologie

Hopital J. VerdierHopital J. Verdier

BONDY 93143BONDY 93143

et Université Paris XIIIet Université Paris XIII

PHC JANUARY 07

EVALUATION OF FIBROSIS : WHY ?EVALUATION OF FIBROSIS : WHY ?

Causal agentCausal agent

Chronic liver Chronic liver

DiseaseDisease

CirrhosisCirrhosis

DecompensationDecompensation Hepatocellular Hepatocellular

2 % to 5 % per year2 % to 5 % per year carcinoma carcinoma

2 % to 5 % per year2 % to 5 % per year

Death

4 % per year

Fibrosis

Distorted architecture

Portal hypertension

Liver failure

Carcinogenesis

FIBROSIS

ASSESSMENT OF FIBROSIS : WHY ?ASSESSMENT OF FIBROSIS : WHY ?

Management of individual patientsManagement of individual patients• Significant fibrosisSignificant fibrosis TreatmentTreatment• CirrhosisCirrhosis Screening for varices and HCCScreening for varices and HCC

Evaluation of treatmentsEvaluation of treatments• Antiviral and antifibrotic drugsAntiviral and antifibrotic drugs

Screening for cirrhosis or extensive fibrosisScreening for cirrhosis or extensive fibrosis• In high risk patientsIn high risk patients

EVALUATION OF FIBROSIS : HOW ?EVALUATION OF FIBROSIS : HOW ?

- Liver biopsy- Liver biopsy

- Blood tests- Blood tests• Genuine serum markers of fibrosis : Genuine serum markers of fibrosis :

by products of extracellular matrixby products of extracellular matrix

metabolism.metabolism.

• Probabilistic indexes = surrogate markers.Probabilistic indexes = surrogate markers.

- Fibroscan - Fibroscan ( transcient elastography)( transcient elastography)

LIVER BIOPSY : LIMITATIONSLIVER BIOPSY : LIMITATIONS

• AcceptabilityAcceptability- patients are often reluctant- patients are often reluctant- even some doctors are reluctant- even some doctors are reluctant

• CostCost• MorbidityMorbidity• ReliabilityReliability

- liver sample size ideally - liver sample size ideally ≥ 25 mm≥ 25 mm- pathologist’s experience- pathologist’s experience- suboptimal reproductibility of scoring systems- suboptimal reproductibility of scoring systems- quantitative assessment unpractical- quantitative assessment unpractical

LENGH OF LIVER BIOPSYLENGH OF LIVER BIOPSY

Biopsy length

Bedossa et al, Hepatology 2003

LIVER BIOPSY : PROS AND CONSLIVER BIOPSY : PROS AND CONS

PROPRO. Not influenced by extrahepatic conditions . Not influenced by extrahepatic conditions . Allows analysis of elementary lesions and comobidities. Allows analysis of elementary lesions and comobidities. May allow assessment of fibrogenesis (molecular . May allow assessment of fibrogenesis (molecular biology)biology)

CONCON. Sampling error. Sampling error. Dependant of pathologist’s experience. Dependant of pathologist’s experience. Unavalaible in large parts of the world. Unavalaible in large parts of the world

BLOOD TESTSBLOOD TESTS

Matrix relatedMatrix relatedPIIINP, collagen type IV, lamininPIIINP, collagen type IV, lamininHyaluronic acid, MMP, TIMPHyaluronic acid, MMP, TIMP

Non maxtrix relatedNon maxtrix relatedAST, ALT, gamma GTAST, ALT, gamma GTBilirubin, prothrombine, plateletsBilirubin, prothrombine, plateletsGammaglobulins, ferritinGammaglobulins, ferritinAlpha 2 macroglobulin, haptoglobinAlpha 2 macroglobulin, haptoglobinApo A1, cholesterol, HOMAApo A1, cholesterol, HOMA

Poynard, 1991Poynard, 1991 Prothrombine, GGT, Apo A1Prothrombine, GGT, Apo A1 PGAPGA

Bonacini, 1997Bonacini, 1997 AST/ALAT, platelets, prothrombineAST/ALAT, platelets, prothrombineImbert-Bismut,Imbert-Bismut, 20012001 bili, GGT, hapto., a2MG, apoA1bili, GGT, hapto., a2MG, apoA1 FibrotestFibrotestLuo,Luo, 20022002 glob/alb, platelets, AST/ALTglob/alb, platelets, AST/ALTForns,Forns, 20022002 age, GGT, cholesterol, plateletsage, GGT, cholesterol, plateletsKaul,Kaul, 20022002 sex, ang.spider angiomas, AST, plateletssex, ang.spider angiomas, AST, plateletsWai, 2003Wai, 2003 AST/plateletsAST/platelets APRIAPRISud, 2004Sud, 2004 age, AST, cholesterol, HOMA, alcoholage, AST, cholesterol, HOMA, alcoholLainé, 2004Lainé, 2004 hyaluronate, transferinhyaluronate, transferinRosenberg,Rosenberg, 20042004 age, hyalur., col IV, col VI, laminin, PIIINP, TIMP-1 age, hyalur., col IV, col VI, laminin, PIIINP, TIMP-1 ELFELFPatel,Patel, 20042004 TIMP-1, a2MG, hyaluronateTIMP-1, a2MG, hyaluronate FibrospectFibrospectLeroy,Leroy, 20042004 PIIIMP, MMP1PIIIMP, MMP1Hui,Hui, 20052005 BMI, platelets, albumin, bilirubinBMI, platelets, albumin, bilirubinLok,Lok, 20052005 AST/ALT, platelets, INRAST/ALT, platelets, INRAdams,Adams, 20052005 bili, GGT, hyaluronate, a2MG, age, sexbili, GGT, hyaluronate, a2MG, age, sex HepascoreHepascoreCales,Cales, 20052005 AST, platelets, prothrombine, hyaluronate, AST, platelets, prothrombine, hyaluronate, FibrometreFibrometre

urea, ageurea, age

BLOOD TESTSBLOOD TESTS

Imbert-Bismut et al. Lancet 2001;357:2069-75Imbert-Bismut et al. Lancet 2001;357:2069-75

Fibrotest ®Fibrotest ®

BLOOD TESTSBLOOD TESTS

MetavirMetavirindexindex

VHC (n= 339)VHC (n= 339)

Imbert-Bismut et al. Lancet 2001;357:2069-75Imbert-Bismut et al. Lancet 2001;357:2069-75

Fibrotest ®Fibrotest ®

BLOOD TESTSBLOOD TESTS

HCV (n=339)

Métavir ≥ F2

AUC = 0,827

Index < 0,10 NPV 100% Index > 0,60 PPV > 90%

Liver Biopsy: - 46%

BLOOD TESTSBLOOD TESTS

Ref.Ref. TestTest AUCAUC

ConstructionConstruction ValidationValidation

Imbert-Bismut, 2001Imbert-Bismut, 2001 FibrotestFibrotest 0.830.83 0.850.85

Forns, 2002Forns, 2002 0.860.86 0.810.81

Wai, 2003Wai, 2003 APRIAPRI 0.800.80 0.880.88

Patel, 2004Patel, 2004 FibrospectFibrospect 0.830.83

Rosenberg, 2004Rosenberg, 2004 ELFELF 0.780.78

Leroy, 2004Leroy, 2004 0.820.82

Sud, 2004Sud, 2004 0.840.84

Adams, 2005Adams, 2005 HepascoreHepascore 0.850.85 0.820.82

HCV : F0-1 vs F2-3-4F0-1 vs F2-3-4HCV : F0-1 vs F2-3-4F0-1 vs F2-3-4

BLOOD TESTSBLOOD TESTS

Ref.Ref. TestTest AUCAUC

ConstructionConstruction ValidationValidation

Kaul, 2002Kaul, 2002 0.940.94

Wai, 2003Wai, 2003 APRIAPRI 0.890.89 0.940.94

Rosenberg, 2004Rosenberg, 2004 ELFELF 0.890.89

Le Calvez, 2004Le Calvez, 2004 FibrotestFibrotest 0.920.92

Adams, 2005Adams, 2005 HepascoreHepascore 0.940.94 0.890.89

Lok, 2005Lok, 2005 0.780.78 0.810.81

HCV : F0-1-2-3 vs F4 (cirrhosis)F0-1-2-3 vs F4 (cirrhosis)HCV : F0-1-2-3 vs F4 (cirrhosis)F0-1-2-3 vs F4 (cirrhosis)

PROPRO

. Easy, non invasive,not too costy. Easy, non invasive,not too costy

. Allow to split patients in 3 groups. Allow to split patients in 3 groups- those without significant fibrosis- those without significant fibrosis- those with extensive fibrosis or cirrhosis- those with extensive fibrosis or cirrhosis- intermediate- intermediate

CONCON

. Studied mainly in naive patients with HCV chronic hepatitis. Studied mainly in naive patients with HCV chronic hepatitis

. External validation lacking (except fibrotest). External validation lacking (except fibrotest)

. Require standardisation of biochemical methods. Require standardisation of biochemical methods

. Poorer performances in HBV patients or coinfected HCV-HIV. Poorer performances in HBV patients or coinfected HCV-HIV

. Possible influence of extrahepatic conditions. Possible influence of extrahepatic conditions

. No international consensus. No international consensus

BLOOD TESTS : PROS AND CONSBLOOD TESTS : PROS AND CONS

2.5 cm

4 cm

1 cm

Volume

ELASTOMETRY (FIBROSCAN)ELASTOMETRY (FIBROSCAN)

ProbeProbe

Sandrin et al. Ultrasound Med Biol 2003;29:1-8Sandrin et al. Ultrasound Med Biol 2003;29:1-8

LB x 100LB x 100

HOW TO MEASURE ELASTICITY ?HOW TO MEASURE ELASTICITY ?

To generate an elasticTo generate an elastic

Shear vaweShear vawe

To measure its spead VsTo measure its spead Vs

ElasticityElasticity

E E V VSS22

2.5 cm

4 cm

1 cm

Volume of exploration

Volume of exploration > 3 cmVolume of exploration > 3 cm33

Probe position

Probe

PATIENTS WITH HCV CHRONIC HEPATITISPATIENTS WITH HCV CHRONIC HEPATITIS

327 HCV + patients

with no ascites

251 patients

included

53 patients excludedbiopsy not suitable for fibrosis

stage assessment: less than 10 portal tracts in the absence of

cirrhosis

23 patients excluded:unreliable stiffness measurement: success rate less than 60% upon

10 measurements

Small biopsy

126 patients

Large biopsy

125 patients

BOX PLOTS. N=251BOX PLOTS. N=251

F01 F2 F3 F410

0

101

102

Ela

stic

ity (

kP

a)

Fibrosis stage0-1 2 3 4

100

1

10

Fibrosis stage (METAVIR)

median IQR

maximum

minimum

Legend

Sti

ffn

ess (

kP

a)

(log

ari

thm

ic s

cale

)

0.0

0.2

0.4

0.6

0.8

1.0

0.0 0.2 0.4 0.6 0.8 1.0

1-Specificité

Sen

sib

ilit

é

F01 / F234

F012 / F34

F0123 / F4

AUROCAUROC

( CONFIDENCE ( CONFIDENCE INTERVALS 95%)INTERVALS 95%)

- - F≥2 : 0.79 (0.73-0.84)F≥2 : 0.79 (0.73-0.84)

- F≥3 : 0.91 (0.87-0.96)- F≥3 : 0.91 (0.87-0.96)

- F=4 : 0.97 (0.93-1.00)- F=4 : 0.97 (0.93-1.00)

F≥2

F≥3

F=4

ROC CURVESROC CURVES

UNI AND MULTIVARIATE ANALYSISUNI AND MULTIVARIATE ANALYSIS

Univariate analysisUnivariate analysis (Kendall’s coefficient)(Kendall’s coefficient)

FibrosisFibrosis Activity Activity Steatosis Steatosis

StiffnessStiffness rr 0.550.55 0.210.21 0.19 0.19pp <0.0001<0.0001 0.00030.0003 0.0008 0.0008

FibrosisFibrosis rr -- 0.360.36 0.17 0.17pp -- <0.0001<0.0001 0.008 0.008

Multivariate analysisMultivariate analysis (multiple regression)(multiple regression)

Only fibrosisOnly fibrosis was significantly correlated to liver stiffness measurement.was significantly correlated to liver stiffness measurement.

0

0.2

0.4

0.6

0.8

1

0 0.2 0.4 0.6 0.8 1

1 - Specificity

Se

ns

itiv

ity

F01 versus F234

F012 versus F34

F0123 versus F4

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

METAVIRMETAVIR

FF 00 11 22 33 44

%% 66 3939 3131 1010 1144

AA 00 11 22 33%% 66 5656 3535 33

SteatosisSteatosisSS 00

1-1-1010

11-11-3030

31-31-100100

%%4477

2727 1515 1010

Univariate Spearman correlationMETAVIR F: 0.70 (p << 0.001)METAVIR A: 0.45 (p << 0.001)Steatosis: 0.35 (p << 0.001)

Area under ROC curves(95% confidence interval)F01 versus F234 = 0.84 (0.80-0.87)F012 versus F34 = 0.93 (0.90-0.95)F0123 versus F4 = 0.96 (0.94-0.98)

- Results- Results

- 103 Patients- 103 PatientsCauses : Causes : 71 VHC71 VHC

14 VHB14 VHB

15 VHC+HIV15 VHC+HIV

2 VHB+HIV2 VHB+HIV

1 VHC+VHB1 VHC+VHB

F2 F3 = F4

AUROC 0.94 0.95 0.93

LIVER BIOPSIES > 30 mmLIVER BIOPSIES > 30 mm

F0 F1 F2 F3 F4N 9 58 14 7 15

Fibrosis Score :

CUT-OFF VALUESCUT-OFF VALUES**

ThresholdThreshold SensitivitySensitivity SpecificitySpecificity LRLR

(kPa)(kPa)

F F 2 2 8.78.7 0.550.55 0.840.84 3.53.5

F F 3 3 9.69.6 0.840.84 0.850.85 5.75.7

F = 4F = 4 14.514.5 0.840.84 0.940.94 13.013.0

* Obtained by the jack-knife method.* Obtained by the jack-knife method.

The optimum thresholds were chosen to maximize the The optimum thresholds were chosen to maximize the sum of sensitivity and specificity.sum of sensitivity and specificity.

FIBROSIS AREA FIBROSIS AREA (morphometry)(morphometry)

69 patients with chronic hepatitis C69 patients with chronic hepatitis Cwithout ascites, and previous anti-viral treatmentwithout ascites, and previous anti-viral treatment

- Patients- Patients

F1 F2 F3 F420 21 5 23

- Results- Results

Parameters rFibrosis area METAVIR score 0.66Elasticity METAVIR score 0.65Elasticity fibrosis area 0.74

Spearman correlation testSpearman correlation test

pp < 0.001 < 0.001

Liver elasticity is closely correlated to fibrosis area.

0

10

20

30

40

50

60

70

F1 F2 F3 F4Fibrosis Stage

Ela

sti

cit

é (

kP

a)

0

5

10

15

20

25

Air

e d

e f

ibro

se

(%

)

Elasticité

Aire de fibrose

METAVIRMETAVIR

FIBROSCAN VERSUS BLOOD TESTSFIBROSCAN VERSUS BLOOD TESTS

1

10

100

F1 F2 F3 F4

Fibrosis stage

1

10

100

F1 F2 F3 F4

Fibrosis stage

0.0

0.3

0.7

1.0

F1 F2 F3 F4

Fibrosis stage

0.0

2.0

4.0

6.0

F1 F2 F3 F4

Fibrosis stage

Ela

stic

ité

(kP

a)

FibroScan FibroTest APRI

Score METAVIR de fibrose Score METAVIR de fibrose Score METAVIR de fibrose

Castera Al. Gastroenterology 2005

CONCORDANCE WITH LIVER BIOPSYCONCORDANCE WITH LIVER BIOPSY

F01/F234 F012/F34 F0123/F4APRI 0.78 0.84 0.83FibroTest 0.85 0.90 0.87FibroScan 0.83 0.90 0.95Combinaison 0.88 0.95 0.95FibroTest+FibroScan

• AUROC

• Percentage of concording results

F01/F234 F0123/F4FibroTest 80 81FibroScan 73 83Combinaison 84 95FibroTest+FibroScan

PROPOSED COMBINATION OF NON PROPOSED COMBINATION OF NON INVASIVE METHODSINVASIVE METHODS

FibroScan + FibroTest

ConcordanceDiscordance

Fibrose minime(FS < 7.1 kPa

+ FT < F2)

Fibrose modérée(FS 7.1 kPa

+ FT F2)

Fibrose sévère(FS 9.5 kPa

+ FT F3)Biopsy

Follow-up TreatmentTreatment

HCC screening Follow-uptreatment

Castera et Al. Gastroenterlogy 2005

FIBROSCAN IN HBV PATIENTS202 patients

- 15 non interpretable biopsies

- 14 LSM considered as non reliable

Statistical analysis on 173 patients

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.2 0.4 0.6 0.8 1

1 - Specificity

Se

ns

itiv

ity

F01 versus F234

F0123 versus F34

F0123 versus F4

AUROC

F01 versus F234: 0.81 (0.73-0.86)

F012 versus F34: 0.93 (0.88-0.96)

F0.123 versus F4: 0.93 (0.82-0.98)

FIBROSCAN PROS AND CONSFIBROSCAN PROS AND CONS PROPRO

-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

CONCON- high rate of failure in obese patients

- doesn’t take in account liver architecture- disturbed in acute conditions

SCREENING IN HIGH RISK PATIENTSSCREENING IN HIGH RISK PATIENTS

41

34

33

LSM

Blood tests

Confirmation of cirrhosis

LB

LSM>13 kPaoui

Absence of cirrhosis

Suspectedcirrhosis

non

227 patients in alcoholic abstinence program

BEFORE BEFORE TREATMENTTREATMENT

END OF END OF TREATMENTTREATMENT

6 MONTHS 6 MONTHS AFTERAFTER

All (n=85)All (n=85) 14.1 14.1 ± 7.2± 7.2 10.9 10.9 ± 6.5± 6.5 11.2 11.2 ± 8.6± 8.6

SVRSVR 12.0 12.0 ± 6.7± 6.7 9.1 9.1 ± 3.7± 3.7 7.5 7.5 ± 2.4± 2.4

RRRR 14.6 14.6 ± 5.6± 5.6 11.5 11.5 ± 5.0± 5.0 12.8 12.8 ± 7.2± 7.2

NRNR 16.9 16.9 ± 8.1± 8.1 13.3 13.3 ± 9.1± 9.1 16.1 16.1 ± 12.2± 12.2

FOLLOW-UP OF LSM IN TREATED PATIENTS WITH CHRONIC HEPATITIS C

CONCLUSIONCONCLUSION

1) Liver biopsy has been partly challenged by non 1) Liver biopsy has been partly challenged by non invasive methods for assessment of liver fibrosisinvasive methods for assessment of liver fibrosis

2) Non invasive methods have their own limitations : 2) Non invasive methods have their own limitations : 2 might be better than one2 might be better than one

3) Fibroscan could become a useful tool for 3) Fibroscan could become a useful tool for assessing fibrosis variationsassessing fibrosis variations