Commentary: prognostication of chronic hepatitis B - are Fibrotest and Fibroscan the final answers?


One of the main jobs of hepatologists is to predict the prognosis of patients with chronic liver diseases. With this knowledge, we determine the need for therapy, hepatocellular carcinoma (HCC) surveillance and screening for varices. Cirrhosis is the most important prognostic factor.

In a recent report, de Lédinghen et al. performed fibroscan, fibrotest, FIB-4 and aspartate aminotransferase-to-platelet ratio index in 600 patients with chronic hepatitis B and prospectively studied their clinical outcomes.[1] At a median follow-up of 50 months, 25 patients died (13 liver-related) and 4 received liver transplantation. Overall, fibrotest and fibroscan achieved the highest accuracy in prognostication; 97% of patients with liver stiffness below 9 kPa or fibrotest ≤0.73 survived at 5 years.

This article adds to the authors’ previous work on the use of non-invasive tests of fibrosis for prognostication in chronic hepatitis C.[2] Increased liver stiffness by fibroscan also predicts HCC in patients with viral hepatitis.[3, 4] In comparison, although the study by de Lédinghen et al. had reasonable sample size, the small number of clinical events limited accurate estimation of survival data.[1] Their findings should be confirmed by studies with larger sample size and longer follow-up. The role of serial non-invasive tests should also be explored.

Furthermore, cirrhosis is the most important but not the sole prognostic factor. In chronic hepatitis B patients, high hepatitis B virus (HBV) DNA level is strongly associated with HCC,[5] and viral suppression by antiviral therapy can reduce adverse outcomes.[6] A few clinical scores have also incorporated cirrhosis, HBV DNA and other clinical factors in predicting the risk of HCC.[7-9] It would be interesting to assess whether non-invasive tests of fibrosis could replace radiological cirrhosis in these risk scores. Through refining the predictive role of each clinical parameter, we may eventually achieve accurate prognostication for chronic hepatitis B.


Declaration of personal interests: Vincent Wong was an advisory board member of and received paid lecture fee from Gilead. He was also a consultant of Otsuka and Merck, and received travel support from Bristol-Myers Squibb.

Declaration of funding interests: None.