Treatment Rates in Patients with Chronic Hepatitis B after Liver Biopsy

Abstract

Purpose: Clinical practice concerns and recent updates of AASLD Guidelines (“guidelines”) and US algorithm (Keeffe et al., 2006) on treatment of chronic hepatitis B (CHB) (“algorithm”) have focused attention on the interpretation of ALT and HBV DNA levels with the utility of liver biopsy in CHB treatment decisions. Specifically, we focused on the use of liver biopsy in patients with high viral load having either ALT 1–2 × ULN or normal ALT. We also assessed the rates of treatment for CHB patients after the liver biopsy at our center. Methods: Charts of 159 patients with CHB seen in our ambulatory clinics between 1/07 and 5/07 have been reviewed. Patient demographics, laboratory, histology and clinical data were recorded. Results: 159 patients were seen (67% males, mean age of 52.4 years, 60% of Asian ethnicity), and 42 (26%) of them had a liver biopsy. A total of 34 (81%) patients were treated either before or after biopsy (see Table). Overall, 35 of 42 (83%) patients had liver biopsy prior to making initial therapeutic decisions, and 27 of the 35 (77%) patients started treatment. Among 47 patients with ALT 1–2 × ULN, 14 (30%) had a liver biopsy, including 6 subjects who had > stage 1 fibrosis on modified Ishak system. Similarly, among 37 patients with normal ALT and HBV DNA > 20,000 IU/mL (HBeAg-positive) or >2,000 IU/mL (for HBeAg-negative), 11 (30%) had a liver biopsy, including 4 subjects with > stage 1 fibrosis. The majority of liver biopsy was obtained from the group with ALT > 2 × ULN (24 patients). 14 (58%) of those 24 subjects demonstrated > stage 1 fibrosis. The overwhelming reasons for non-treatment were minimal fibrosis in 7 of 8 patients. The remaining one patient who had normal ALT and stage 2 fibrosis deferred treatment. Treatment was started in 13 patients with < stage 2 fibrosis, mainly due to increased ALT values or a family history of hepatocellular carcinoma. Conclusion: A liver biopsy was helpful in selecting treatment for patients with mild ALT elevation. A majority of patients with CHB undergoing liver biopsy received antiviral therapy afterwards. A large proportion of patients undergoing liver biopsy with normal ALT and high viral load had significant liver fibrosisTable