Page 14 - NON-INVASIVE TESTS FOR EVALUATION OF LIVER DISEASE SEVERITY AND PROGNOSIS
P. 14
JOURNAL OF HEPATOLOGY
Hepatitis B
Treatment-naive
Measurement of liver stiffness (TE)
Normal ALT Elevated ALT but <5 x ULN
<6 kPa 6-9 kPa >9 kPa <6 kPa 6-12 kPa >12 kPa
No significant Grey Severe fibrosis No significant Grey Severe fibrosis
fibrosis area cirrhosis fibrosis area cirrhosis
Whatever HBV DNA level Exclude other Whatever HBV DNA level
and causes of and
HBeAg status elevated ALT HBeAg status
Consider Liver biopsy Consider treatment Consider Liver biopsy Consider treatment
follow-up TE if if results influence screening for varices follow-up TE
HBV DNA >2000
management and HCC if results influence screening for varices
IU/ml
management and HCC
Fig. 2. Proposed algorithm for the use of transient elastography in treatment-naive patients with Hepatitis B.
once by non-invasive tests. Once a diagnosis of cirrhosis has been [198,202]. Among inactive carriers with normal transaminases,
established, both AASLD and EASL guidelines recommend that TE also has less fluctuation over time as compared to
those patients should be screened for PH and HCC [213,214]. FibroTestÒ or APRI score [155]. LS of <5–6 kPa often indicates
Therefore all HCV patients need to be staged as part of routine absent or minimal liver fibrosis [132,153]. On the other hand,
HCV care to exclude cirrhosis. The diagnostic accuracy of TE for LS of >12–14 kPa often indicates liver cirrhosis (Table 5).
cirrhosis has been confirmed by multiple studies and meta- Among patients with intermediate LS measurements, the
analyzes and has proven superior to that reported by serum accuracy of staging is lower. In doubtful cases, liver biopsy is
biomarkers. recommended (Fig. 2). Among chronic hepatitis B patients who
have elevated ALT levels or ALT flares, interpretation of LS mea-
Recommendations surement should be taken with caution. LS can be misleadingly
high among patients who have severe acute exacerbation of
• All HCV patients should be screened to exclude chronic hepatitis B, even 3–6 months after ALT has been normal-
cirrhosis by TE if available. Serum biomarkers can be ized [215].
used in the absence of TE (A1)
For HBeAg-positive patients, particularly among those who
• HCV patients who were diagnosed with cirrhosis based are older than 35 years of age with high normal ALT levels,
on non-invasive diagnosis should undergo screening non-invasive assessment of liver fibrosis is useful to differentiate
for HCC and PH and do not need confirmatory liver whether patients are in immune tolerance phase or already have
biopsy (A1) significant liver fibrosis secondary to immune clearance [216].
HBV In HBeAg-negative patients, the low replicative phase is indi-
In chronic hepatitis B, TE generally has a higher AUROC as com- cated by normal ALT level and low HBV DNA (<2000 IU/ml). On
pared to serum biomarkers for advanced liver fibrosis the other hand, the reactivation phase is characterized by ele-
vated HBV DNA levels with intermittent elevation of ALT levels.
Patients who have repeated and prolonged reactivation have
higher risks of developing liver cirrhosis [217]. Non-invasive
assessment of liver fibrosis is preferred over liver biopsy among
HBeAg-negative patients with low (<2000 IU/ml) or borderline
(>2000 to 20,000 IU/ml) HBV DNA and normal ALT levels, as the
Journal of Hepatology 2015 vol. xxx j xxx–xxx 13
Please cite this article in press as: EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J
Hepatol (2015), http://dx.doi.org/10.1016/j.jhep.2015.04.006
Hepatitis B
Treatment-naive
Measurement of liver stiffness (TE)
Normal ALT Elevated ALT but <5 x ULN
<6 kPa 6-9 kPa >9 kPa <6 kPa 6-12 kPa >12 kPa
No significant Grey Severe fibrosis No significant Grey Severe fibrosis
fibrosis area cirrhosis fibrosis area cirrhosis
Whatever HBV DNA level Exclude other Whatever HBV DNA level
and causes of and
HBeAg status elevated ALT HBeAg status
Consider Liver biopsy Consider treatment Consider Liver biopsy Consider treatment
follow-up TE if if results influence screening for varices follow-up TE
HBV DNA >2000
management and HCC if results influence screening for varices
IU/ml
management and HCC
Fig. 2. Proposed algorithm for the use of transient elastography in treatment-naive patients with Hepatitis B.
once by non-invasive tests. Once a diagnosis of cirrhosis has been [198,202]. Among inactive carriers with normal transaminases,
established, both AASLD and EASL guidelines recommend that TE also has less fluctuation over time as compared to
those patients should be screened for PH and HCC [213,214]. FibroTestÒ or APRI score [155]. LS of <5–6 kPa often indicates
Therefore all HCV patients need to be staged as part of routine absent or minimal liver fibrosis [132,153]. On the other hand,
HCV care to exclude cirrhosis. The diagnostic accuracy of TE for LS of >12–14 kPa often indicates liver cirrhosis (Table 5).
cirrhosis has been confirmed by multiple studies and meta- Among patients with intermediate LS measurements, the
analyzes and has proven superior to that reported by serum accuracy of staging is lower. In doubtful cases, liver biopsy is
biomarkers. recommended (Fig. 2). Among chronic hepatitis B patients who
have elevated ALT levels or ALT flares, interpretation of LS mea-
Recommendations surement should be taken with caution. LS can be misleadingly
high among patients who have severe acute exacerbation of
• All HCV patients should be screened to exclude chronic hepatitis B, even 3–6 months after ALT has been normal-
cirrhosis by TE if available. Serum biomarkers can be ized [215].
used in the absence of TE (A1)
For HBeAg-positive patients, particularly among those who
• HCV patients who were diagnosed with cirrhosis based are older than 35 years of age with high normal ALT levels,
on non-invasive diagnosis should undergo screening non-invasive assessment of liver fibrosis is useful to differentiate
for HCC and PH and do not need confirmatory liver whether patients are in immune tolerance phase or already have
biopsy (A1) significant liver fibrosis secondary to immune clearance [216].
HBV In HBeAg-negative patients, the low replicative phase is indi-
In chronic hepatitis B, TE generally has a higher AUROC as com- cated by normal ALT level and low HBV DNA (<2000 IU/ml). On
pared to serum biomarkers for advanced liver fibrosis the other hand, the reactivation phase is characterized by ele-
vated HBV DNA levels with intermittent elevation of ALT levels.
Patients who have repeated and prolonged reactivation have
higher risks of developing liver cirrhosis [217]. Non-invasive
assessment of liver fibrosis is preferred over liver biopsy among
HBeAg-negative patients with low (<2000 IU/ml) or borderline
(>2000 to 20,000 IU/ml) HBV DNA and normal ALT levels, as the
Journal of Hepatology 2015 vol. xxx j xxx–xxx 13
Please cite this article in press as: EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J
Hepatol (2015), http://dx.doi.org/10.1016/j.jhep.2015.04.006
