Alimentary Pharmacology and Therapeutics SUMMARY. Background Metabolic syndrome is a known risk factor of cirrhosis in chronic hepatitis B (CHB).

Transcription

1 Alimentary Pharmacology and Therapeutics Coincidental metabolic syndrome increases the risk of liver fibrosis progression in patients with chronic hepatitis B a prospective cohort study with paired transient elastography examinations G. L.-H. Wong*,,, H. L.-Y. Chan*,,,Z.Yu, A. W.-H. Chan, P. C.-L. Choi, A. M.-L. Chim*,,, H.-Y. Chan*,,, C.-H. Tse*,, & V. W.-S. Wong*,, *Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China. Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China. State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China. Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China. Correspondence to: Dr V. W.-S. Wong, Department of Medicine and Therapeutics, 9/F Prince of Wales Hospital, Ngan Shing Street, Shatin, Hong Kong SAR, China. wongv@cuhk.edu.hk Publication data Submitted 18 December 2013 First decision 6 January 2014 Resubmitted 15 January 2014 Accepted 23 January 2014 EV Pub Online 20 February 2014 This article was accepted for publication after full peer-review. SUMMARY Background Metabolic syndrome is a known risk factor of cirrhosis in chronic hepatitis B (CHB). Aim To investigate the effects of coincidental metabolic syndrome on liver fibrosis progression in treatment-na ıve CHB patients. Methods A total of 1466 CHB patients underwent liver stiffness measurement (LSM) by transient elastography in ; 663 patients remained treatment-na ıve and had second LSM in Liver fibrosis progression was defined as an increase in LSM 30% at the second assessment. The impact of coincidental metabolic syndrome and its factors on liver fibrosis progression were evaluated after adjustment for viral load and hepatitis activity. Results At baseline, the mean age was years, 55% were males, serum alanine aminotransferase (ALT) was IU/L, HBV DNA was log IU/mL and LSM was kpa. Metabolic syndrome was diagnosed in 80 (12%) and 142 (21%) patients at baseline and follow-up visit, respectively; 84 (13%) and 22 (3%) patients had coincidental and resolved metabolic syndrome respectively. After an interval of 44 7 months, 107 (16%) patients developed liver fibrosis progression. Coincidental metabolic syndrome [adjusted odds ratio (aor) 2.0, 95% confidence interval (CI) , P = 0.015], central obesity (aor 2.0, 95% CI , P = 0.05) and low level of high-density lipoprotein cholesterol (aor 1.9, 95% CI , P = 0.04) were associated with liver fibrosis progression independent of change in viral load and ALT level. The effects of coincidental metabolic syndrome were most apparent in the immune-tolerant phase. Conclusion Coincidental metabolic syndrome increases the risk of liver fibrosis progression in patients with chronic hepatitis B infection, independent of viral load and hepatitis activity. Aliment Pharmacol Ther 2014; 39: doi: /apt.12658

2 G. L.-H. Wong et al. INTRODUCTION Chronic hepatitis B (CHB) is one of the leading causes of liver fibrosis, which may subsequently lead to cirrhosis, hepatocellular carcinoma (HCC) and death. 1 Potential risk factors for progression from mild to advanced liver fibrosis include older age, male gender, alcohol use, co-infection with hepatitis C virus, hepatitis D virus, or human immunodeficiency virus, elevated alanine aminotransferase (ALT) levels, high hepatitis B virus (HBV) DNA level and, possibly, hepatitis B virus genotype/subgenotype. 2, 3 Liver cirrhosis is one of the most important risk factors of HCC development. 4, 5 Recent data demonstrated that metabolic syndrome is a risk factor of advanced liver fibrosis and cirrhosis independent of viral factors in CHB. 6 Metabolic syndrome, comprising of type 2 diabetes, hypertension, central obesity and dyslipidaemia, is increasingly prevalent worldwide including Asia. 7 A dose response relationship between the number of components of metabolic syndrome and the risk of advanced fibrosis was observed in CHB patients. 6 In fact, metabolic factors and adipokines probably play a role on liver fibrosis independent of viral factors in CHB patients. 8 Therefore, the dynamic and interactive effect of viral and metabolic factors on liver fibrosis warrants further investigation in a prospective study. Transient elastography by Fibroscan (Echosens, Paris, France) has been developed as an accurate, reproducible and non-invasive test for the assessment of advanced liver fibrosis. 9 It has been widely validated in different liver diseases such as CHB 10, 11 and non-alcoholic fatty liver disease (NAFLD). 12 This non-invasive tool makes it possible to perform repeated liver fibrosis assessments on a large number of asymptomatic patients cross-sectionally 13, 14 15, 16 and serially. In this study, we aimed to investigate the effect of the dynamic changes of metabolic and viral profiles on liver fibrosis progression in treatment-na ıve CHB patients. The effects of coincidental metabolic syndrome and individual metabolic risk factor were also assessed. PATIENTS AND METHODS Study population From 2006 to 2008, we conducted a territory-wide screening study on the prevalence of advanced liver fibrosis, in relation to the presence of metabolic syndrome, in CHB patients. 6 Over 1466 patients from both primary care clinics and hospitals in different regions of Hong Kong were recruited. We included patients with CHB, which was diagnosed by positive serology tests for serum hepatitis B surface antigen (HBsAg) for at least 6 months. We excluded patients with evidence of chronic hepatitis C by screening with antibody against hepatitis C virus. We interviewed every patient with a standardised questionnaire and excluded men who consumed more than 30 grams of alcohol per week and women who consumed more than 20 g of alcohol per week. Secondary causes of hepatic steatosis (e.g. chronic use of systemic corticosteroids and methotrexate) were also excluded. We also excluded patients who had decompensated liver disease, complications of liver cirrhosis, hepatocellular carcinoma, previous liver surgery or liver transplantation. 6 At that time, transient elastography, biochemical and virological assays were performed on every patient. In , we invited the patients who remained treatment-na ıve for follow-up assessments including transient elastography at least 3 years from baseline. The local ethics committee approved the study protocol, and all patients gave written informed consent before enrolled into the study. Clinical evaluation All patients received comprehensive clinical and laboratory (haematological, biochemical and virological) assessments at baseline and follow-up visits. The medical history and physical examination were specifically recorded with a standard questionnaire. Anthropometric parameters including body weight, body height, hip circumference and waist circumference were measured. Body mass index (BMI) was calculated as weight (kg) divided by height (m) squared. Overweight was defined as BMI 23 kg/m 2, and obesity BMI 25 kg/m 2, according to the Asian and Chinese criteria. 17 Serum HBV DNA levels were measured by the TaqMan real-time polymerase chain reaction assay with a range of detection 20 to IU/mL. 18 HBsAg was quantified by Architect HBsAg QT (Abbott Diagnostic, Abbott Park, North Chicago, IL, USA), with a final range of detection IU/mL. 19 Definition of coincidental metabolic syndrome Metabolic syndrome was defined according to the modified NCEP criteria. 20 The presence of any three of the following five factors is required for a diagnosis of metabolic syndrome: (i) central obesity (waist circumference 90 cm for men and 80 cm for women); (ii) raised concentration of triglycerides (TG 1.7 mmol/l or specific treatment for this lipid abnormality); (iii) reduced concentration of high-density lipoprotein-cholesterol (HDL-C <1.03 mmol/ L in men and <1.29 mmol/l in women or specific treatment for this lipid abnormality); (iv) raised blood pressure (systolic blood pressure 130 mmhg or diastolic blood 884 Aliment Pharmacol Ther 2014; 39:

3 Coincidental metabolic syndrome and fibrosis progression in HBV pressure 85 mmhg or treatment of previously diagnosed hypertension); and (v) raised fasting plasma glucose concentration 5.6 mmol/l or previously diagnosed type 2 diabetes mellitus (DM). Coincidental metabolic syndrome or metabolic factor was defined as the newly diagnosed condition at the follow-up assessments among patients who were free from the condition at the baseline visit. Resolved metabolic syndrome or metabolic factor was defined as the absence of condition at the follow-up assessments among patients who had the condition at the baseline visit. Definition of liver fibrosis progression and regression by LSM Liver stiffness measurement was performed using transient elastography according to the instructions and training provided by the manufacturer as previously described. 21 The LSM was considered reliable only if 10 successful acquisitions were obtained with an interquartile range (IQR) 30% of LSM. 22 The liver stiffness was expressed in kilopascal (kpa). At baseline visit, 0.2% and 4.1% of entire cohort (1532 patients) had failed and unreliable measurements; all measurements were by M probe. Liver fibrosis progression was defined as an LSM value increased for >30% from baseline; regression was defined as that decreased for >30% from baseline. 23 Definition of different phases of chronic hepatitis B Different phases of CHB were defined according to latest international guidelines Immune-tolerant phase was defined as positive hepatitis B e antigen (HBeAg) with normal serum ALT of local laboratory and HBV DNA > IU/mL. Immune-clearance phase was defined as positive HBeAg with elevated ALT. HBeAg seroconversion was defined as the loss of HBeAg turned and the appearance of its antibody (anti-hbe). HBeAg seroreversion happened with reappearance of HBeAg. HBeAg-negative inactive state was defined as negative HBeAg with normal serum ALT and HBV DNA <2000 IU/mL. HBeAg-negative hepatitis state was defined as negative HBeAg with elevated serum ALT and/or HBV DNA 2000 IU/mL. Internal validation of LSM with liver biopsy The accuracy of LSM to detect advanced fibrosis and cirrhosis was internally validated in a subgroup of patients who had liver biopsy within 1 month of the transient elastography examination. Percutaneous liver biopsy was performed using the 16G Temno needle. Liver histology was assessed by pathologists specialised in liver diseases (P.C.L.C., A.W.H.C.) without knowledge of the clinical data. A liver sample was considered adequate if it was longer than 15 mm and contained 6 portal tracts or more. Liver fibrosis was evaluated semi-quantitatively according to the Ishak scoring system ranges from 0 to Bridging fibrosis was defined as Ishak fibrosis stage 4 and liver cirrhosis as Ishak fibrosis score of 5 or 6. Sample size and statistical analyses Over 1400 CHB patients had valid transient elastography results at baseline. 6 With an estimation of approximately 50% remaining treatment-na ıve and a response rate of 80%, around 600 patients would be included in this follow-up analysis. This sample size would achieve a 95% confidence interval (CI) of 2 6% for an annual incidence of fibrosis progression of 3 5%. Statistical analysis was performed by Statistical Package for Social Science (IBM SPSS Statistical Professional version 20.0; IBM, Armonk, NY, USA). Continuous variables were expressed in mean standard deviation or median (range) as appropriate. Qualitative and quantitative differences between subgroups were analysed by Chi-square or Fisher s exact tests for categorical parameters and Student s t-test or Mann Whitney tests for continuous parameters as appropriate. The annual incidence rate was estimated by dividing the total number of liver fibrosis progression by the summation of person-time calculated in years. Multivariable analysis by logistic regression model adjusted for the change in serum ALT and HBV DNA level was performed to investigate the relationship between metabolic syndrome and its factors and liver fibrosis progression. Effect sizes were expressed in adjusted odds ratios (aor) and 95% CI. All statistical tests were two-sided. Statistical significance was taken as P < RESULTS Patient characteristics at baseline visit One thousand four hundred and seven patients who fulfilled the inclusion criteria formed the target population; 1193 patients responded and underwent follow-up assessments between January 2010 and May After excluding 530 patients who had received anti-viral therapy after the first visit, 663 treatment-na ıve patients were included in the final analysis (Figure 1). The demographic, virological and clinical characteristics of the patients at baseline and follow-up visits are summarised in Table 1. Their age at baseline was years; none of them had weekly alcohol consumption of more than 10 g. The baseline ALT level was IU/L, 82% of which were within the normal range; 77% had Aliment Pharmacol Ther 2014; 39:

4 G. L.-H. Wong et al. negative HBeAg; their HBV DNA level was log 10 IU/mL, 37% of which were <2000 IU/ ml. All LSM results were reliable. The LSM value was kpa; the IQR/LSM ratio , and the success rate of acquisition was 89 13%. Eighty patients (12%) had metabolic syndrome at baseline. The most prevalent metabolic factor was central obesity (299 patients, 45%), followed by hypertension (209 patients, 32%), reduced HDL-C (98 patients, 18%), raised TG (81 patients, 12%) and DM (70 patients, 11%). Patient characteristics at follow-up visit The duration between baseline and follow-up assessments was 44 7 months. None of the patients developed hepatic decompensation during follow-up. Compared with the baseline visit, the ALT level was slightly decreased; the change in ALT level was 4 51 IU/L. The HBV DNA and HBsAg levels significantly decreased to log 10 IU/mL (P < 0.001) and log 1 IU/mL (P = 0.001) respectively. The IQR/LSM ratio was ; the success rate of acquisition was 94 10%. The LSM value was slightly decreased to kpa (P = 0.03). One hundred and forty-two patients (21%) had metabolic syndrome at follow-up; 84 (13%) and 22 (3%) patients had coincidental and resolved metabolic syndrome, respectively. The most prevalent metabolic factor became hypertension (285 patients, 43%), followed by central obesity (276 patients, 42%), DM (166 patients, 25%), raised TG (118 patients, 18%), and reduced HDL-C (79 patients, 12%). The median (range) change in the number of metabolic factors was 0 ( 3 4). Internal validation of LSM with liver biopsy A subgroup of 51 patients underwent liver biopsy and 43 (84%) had adequate liver biopsy samples for histological assessment. The liver biopsy specimens were 19 5 mm in length containing 11 6 portal tracts. The interobserver agreement was 0.93 for fibrosis staging and 1.00 for the presence of Ishak stage 4 fibrosis or above. Thirty (70%), 24 (56%) and 14 (33%) patients had Ishak 2, 3 and 4 disease respectively, whereas 7 (16%) had Ishak 5 to 6 disease (cirrhosis). The 14 patients with advanced fibrosis had not received anti-- viral therapy because of low ( IU/mL) or undetectable serum HBV DNA level in 7 and 4 patients respectively; another 3 patients refused anti-viral therapy. The area under the ROC curves of LSM for Ishak 2 and Ishak 3 was 0.70 (95% CI , P=0.027) and 0.73 (95% CI , P=0.02) 22 died 1 received liver transplantation 21 developed hepatocellular carcinoma 15 lost HBsAg 1466 chronic hepatitis B patients underwent transient elastography between July 2006 and February lost to contact 27 refused follow-up transient elastography 1407 patients fulfilled inclusion criteria 1193 responded and underwent transient elastography between January 2010 and May received antiviral treatment after first transient elastography 663 treatment-naïve patients included in final analysis Figure 1 Patient selection: 663 treatment-na ıve patients were included in the final analysis. 886 Aliment Pharmacol Ther 2014; 39:

5 Coincidental metabolic syndrome and fibrosis progression in HBV Table 1 Clinical characteristics of the patients Baseline visit Follow-up visit P value* Number of patients 663 Follow-up duration 44 7 (months) Male gender 366 (55%) Age (year) <0.001 Body weight (kg) BMI (kg/m 2 ) BMI 25.0 kg/m (23%) 157 (24%) 0.60 Waist circumference, cm Hip circumference, cm Systolic BP, mmhg Diastolic <0.001 BP, mmhg Metabolic syndrome 80 (12%) 142 (21%) <0.001 Central obesity 299 (45%) 276 (42%) 0.20 Raised TG 81 (12%) 118 (18%) Reduced HDL-C 98 (15%) 79 (12%) 0.13 Hypertension 209 (32%) 285 (43%) <0.001 Diabetes mellitus 70 (11%) 166 (25%) <0.001 Coincidental MS N.A. 84 (13%) Resolved MS N.A. 22 (3%) No. of factors 1 (0 5) 1 (0 5) 0.34 Change in N.A. 0 ( 3 4) no. of factors Albumin (g/l) Total bilirubin (lmol/l) ALT (IU/L) Change from N.A baseline (IU/L) Alpha-fetoprotein (lg/l) HBeAg Positive 151 (23%) 112 (17%) 0.02 Negative 510 (77%) 547 (82%) Equivocal 2 (0.3%) 4 (1%) HBV DNA levels <0.001 (log 10 IU/mL) Change N.A (log 10 IU/mL) HBsAg levels <0.001 (log 10 IU/mL) Change N.A (log 10 IU/mL) LSM(kPa) Advanced fibrosis 65 (9.8%) 61 (9.2%) 0.71 Liver fibrosis N.A. 107 (16%) progression Liver fibrosis N.A. 113 (17%) regression IQR/LSM ratio Table 1 (Continued) Success rate of acquisition (%) Fatty liver on ultrasonography* Baseline visit Follow-up visit P value* < (7%) 49 (10%) 0.07 ALT, alanine aminotransferase; BMI, body mass index; BP, blood pressure; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HDL-C, high-density lipoprotein cholesterol; IQR, interquartile range; LSM, liver stiffness measurement; MS, metabolic syndrome; N.A., not applicable; TG, triglycerides. * 550 (83%) and 471 (71%) patients had undergone transabdominal ultrasonography with 6 months of the baseline and follow-up visits respectively. respectively, whereas that for bridging fibrosis and cirrhosis was 0.84 (95% CI , P<0.001) and 0.88 (95% CI , P=0.002) respectively (Figure S1). The ALT-based LSM algorithms had a high sensitivity of 93% and satisfactory specificity of 83% to diagnose bridging fibrosis. Incidence of liver fibrosis progression One hundred and seven patients (16.1%) had increase in LSM of >30% at follow-up visit, hence were defined to have liver fibrosis progression; the annual incidence rate (95% CI) was 4.4% (3.6% 5.3%). Their clinical information is described in Table S1. Serum ALT slightly increased from IU/L at baseline to IU/L at follow-up, but only 6 of them had ALT increased from normal to above the upper limit of normal. The HBV DNA level decreased from log 10 IU/mL at baseline to log 10 IU/mL at follow-up. The HBsAg level slightly decreased from log 10 IU/mL at baseline to log 10 IU/mL at follow-up. Twentythree (23%) and 3 (3%) patients had coincidental and resolved metabolic syndrome respectively at follow-up. Incidence of liver fibrosis regression One hundred and thirteen patients (17.0%) had decrease in LSM of >30% at follow-up visit, hence were defined to have liver fibrosis regression; the annual incidence rate (95% CI) was 4.6% (3.8% 5.8%). Serum ALT decreased from IU/L at baseline to IU/L at follow-up. The HBV DNA level decreased from log 10 IU/mL at baseline to log 10 IU/ ml at follow-up. The HBsAg level slightly decreased Aliment Pharmacol Ther 2014; 39:

6 G. L.-H. Wong et al. from log 10 IU/mL at baseline to log 10 IU/mL at follow-up. Eleven (10%) and 5 (5%) patients had coincidental and resolved metabolic syndrome, respectively, at follow-up. Liver fibrosis progression in different phases of chronic hepatitis B HBeAg-positive patients generally were at higher risk of liver fibrosis progression; it was found in 22.7%, 25.3% and 20.0% of patients in immune-tolerant phase, immune-clearance phase and those had HBeAg seroreversion respectively (Figure 2). HBeAg-negative patients generally were at lower risk of liver fibrosis progression: it was found in 0%, 14.3% and 13.7% in patients who achieved HBeAg seroconversion, those in HBeAgnegative inactive state and HBeAg-negative hepatitis respectively. There seemed no very obvious trend in liver fibrosis regression in different phases of disease. The absolute and percentage changes of LSM in different phases of disease were shown in Figure S2. Coincidental metabolic syndrome and liver fibrosis progression Twenty-three of 84 (22%) patients with coincidental metabolic syndrome developed liver fibrosis progression, compared to 84 of 663 (12%) patients of the entire cohort (P < 0.001). Coincidental metabolic syndrome was found to be a risk factor of liver fibrosis progression independent of the change in serum ALT and HBV DNA levels; its adjusted odds ratio (aor) was 2.0 (95% CI , P = 0.015) when compared with patients who did not have metabolic syndrome at both visits (Table 2). Among the five metabolic factors, coincidental central obesity (aor 2.0, 95% CI , P = 0.05) and low HDL-C level (aor 1.9, 95% CI , P = 0.04) were independent risk factors of liver fibrosis progression. Patients who had resolved metabolic syndrome or its factors, or those had been remained in the conditions did not have significantly increased risk of liver fibrosis progression. On the other hand, there was no obvious association between coincidental or resolved metabolic syndrome and liver fibrosis regression. Interaction between metabolic syndrome and chronic hepatitis B Liver fibrosis progression was more commonly observed in patients with more metabolic risk factors at follow-up visit (Figure 3). In other respects, coincidental metabolic syndrome increased liver fibrosis progression most obviously in the immune-tolerant phase (Figure 4) Fibrosis progression Fibrosis regression Percentage (%) No. of patients Immune tolerant phase Immune clearance phase HBeAg reversion HBeAg-positive states HBeAg seroconversion HBeAg-negative inactive state HBeAg-negative hepatitis HBeAg-negative states Figure 2 Bar charts showing the percentages of liver fibrosis progression and regression according to different phases of chronic hepatitis B. HBeAg-positive patients generally were at higher risk of liver fibrosis progression compared with HBeAg-negative patients. 888 Aliment Pharmacol Ther 2014; 39:

7 Coincidental metabolic syndrome and fibrosis progression in HBV DISCUSSION This is the first prospective study to confirm coincidental metabolic syndrome increases the risk of liver fibrosis progression in patients with chronic hepatitis B who remained treatment-na ıve in 3 4 years. We demonstrated that coincidental metabolic syndrome is a risk factor of liver fibrosis progression independent of viral load and active hepatitis. Central obesity and low HDL-C level are the two most important metabolic factors. The effect of coincidental metabolic syndrome is most apparent in the immune-tolerant phase. We could not demonstrate any significant impact on liver fibrosis from resolved metabolic syndrome, probably because of its low incidence. Liver fibrosis progression is more commonly observed in HBeAg-positive states, regardless of immune-tolerant or immune-clearance phase, compared with the HBeAg-negative states. There were a handful of studies established the association, but not exactly the causal relationship, between metabolic syndrome and cirrhosis. It was because insulin resistance and other metabolic disturbances can be a result of cirrhosis. Our observations clearly demonstrated that metabolic changes precede fibrosis progression, which consolidated our previous observation in a cross-sectional study that metabolic syndrome increases the risk of liver cirrhosis in CHB. 6 A recent Korean biopsy cohort of 850 CHB patients also showed a strong association between metabolic syndrome and advanced fibrosis. 28 Increased risk of advanced liver fibrosis in patients who remain HBeAg-positive above the age of is probably a result from the synergistic effect of high viral load and coincidental metabolic syndrome, which is also known to be increasingly prevalent with age. 29 In fact, HBV infection per se may be associated with a lower prevalence of fatty liver and metabolic syndrome, 30 which is distinct from chronic hepatitis C. 31 The inverse association between chronic HBV infection and fatty liver was also observed in a recent large-scale Taiwanese population study of subjects seeking for check-up. 32 Nonetheless, other investigators also described hepatic steatosis observed in a significant proportion (up to 18%) of CHB patients in absence of significant alcohol consumption Therefore, concomitant NAFLD in CHB patients remains a noteworthy issue. Recent data begin to unveil the mechanisms of metabolic abnormalities and adverse outcomes in CHB. Metabolic syndrome may promote fibrosis progression through a direct stimulation of liver stellate cells by hyperinsulinemia and hyperglycaemia, resulting in increased production of the connective tissue growth factor and subsequent accumulation of extracellular matrix. 36 Hyperinsulinemia is also an independent risk factor for HCC among HBV carriers, especially for those with lower viral load. 37 Oxidative stress and/or lipid peroxidation was found to be involved in the pathogenesis and acceleration of abnormal liver biochemistry in HCC. 38 Obese and diabetic patients receiving long-term Table 2 Multivariable logistic regression analysis on metabolic factors associated with liver fibrosis progression Coincidental Resolved Remained positive Status of metabolic conditions* aor 95% CI P value aor 95% CI P value aor 95% CI P value Liver fibrosis progression Metabolic syndrome Hypertension Diabetes Central obesity Low HDL-C High TG Liver fibrosis regression Metabolic syndrome Hypertension Diabetes Central obesity Low HDL-C High TG AOR, adjusted odds ratio; CI, confidence interval; HDL-C, high-density lipoprotein cholesterol; TG, triglycerides. * Referent to patients remained free from the metabolic conditions at both visits. Adjusted for the change in serum alanine aminotransferase and hepatitis B virus (HBV) DNA levels. Aliment Pharmacol Ther 2014; 39:

8 G. L.-H. Wong et al. Fibrosis progression (%) No. of patients 14.9 At baseline visits to 2 3 to 5 0 No. of metabolic risk factors At follow-up visits to to Figure 3 Bar charts showing the percentages of liver fibrosis progression according to the numbers of metabolic factors at baseline and followup visits. Liver fibrosis progression was more commonly observed in patients with more metabolic risk factors. Fibrosis progression (%) Immune tolerant phase Immune clearance phase HBeAg reversion HBeAg seroconversion HBeAg-negative inactive state HBeAg-negative hepatitis tenofovir disoproxil fumarate for at least 5 years were less likely to have regression of cirrhosis despite viral suppression. 39 All these data highlighted importance of metabolic factors in liver fibrosis progression in CHB. These data also imply that suppressing HBV alone in CHB patients with co-existing metabolic syndrome is not sufficient to reduce the risk of cirrhosis and its complication. These patients may have concomitant non-alcoholic steatohepatitis activity. It was interesting to note that patients with more metabolic risk factors at follow-up visit but not baseline visit were at higher risk of liver fibrosis progression (Figure 3). The relatively low incidence of liver fibrosis progression for patients with more metabolic risk factors at baseline visit was probably an artefact. It was because the patients with advanced fibrosis at baseline related to metabolic syndrome 6 very likely would have received anti-viral therapy; hence they would not have been included in this cohort. Instead patients who had Incident MS Resolved MS Remained MS Remained no MS Remained no MS Remained MS Resolved MS Incident MS Figure 4 Bar charts showing the percentages of liver fibrosis progression according to different phases of chronic hepatitis B and status of metabolic syndrome at two visits. Coincidental metabolic syndrome increased liver fibrosis progression most obviously in the immunetolerant phase. more metabolic risk facts at the follow-up visit and deteriorating metabolic profile were at higher risk of liver fibrosis progression. The prevalence of metabolic syndrome in this cohort was 12% and 21% at baseline and follow-up visit respectively. That at the baseline visit was comparable with the age-standardised prevalence of metabolic syndrome of 13.9% in this locality. 40 The significantly higher prevalence of metabolic syndrome at the follow-up visit up was probably the effect of increasing age of the subjects as well as the time-trend effect, as there has been a consistent increase in the prevalence of metabolic syndrome in the Asian-Pacific region. 41 As CHB is also highly prevalent in this region, the additive effect of metabolic syndrome and CHB on liver fibrosis progression poses significant risk on patients suffered from both conditions. Our findings have a few important clinical implications. First, clinicians taking care of CHB patients should 890 Aliment Pharmacol Ther 2014; 39:

9 Coincidental metabolic syndrome and fibrosis progression in HBV also monitor their metabolic profile. Regular monitoring of anthropometric parameters, blood pressure, fasting lipids and glucose should be integrated into the routine management of all CHB patients. Second, early recognition and management of metabolic syndrome in CHB patients may have a positive effect on their long-term outcome. Lifestyle modifications including physical activity, 42 weight loss 43 and diet 44, 45 do not just favourably affect the various components of metabolic syndrome, but have also been proved effective to reverse fatty liver. 46 Lifestyle advice should not only be provided to CHB patients with metabolic syndrome, but also those at risk of metabolic syndrome (e.g. those with one or two metabolic factors) to avoid the development of a coincidental metabolic syndrome. Our study has the strength of a prospective design involving a large number of patients and respectable length of follow-up, which increased the statistical power and reliability of the results. Nonetheless, our study also has a few limitations. First, transient elastography instead of liver biopsy was used as the diagnostic tool to define liver fibrosis progression. This was because serial liver biopsies in untreated patients may not be readily acceptable to doctors and patients. Instead, we applied one of the most reliable and reproducible non-invasive tests of fibrosis to a large number of patients. The internal validation of the performance of this non-invasive tool supported the fact that it remained accurate in this cohort. Furthermore, the confounding effect from ALT should be minimal in the present study, as most patients had normal ALT at baseline, and even slightly lower at the follow-up visit. Therefore, the increase in LSM was unlikely related to raised ALT levels. Second, a cohort of relatively inactive and treatment-na ıve patients were included in the analysis, as we would like to avoid the confounding effect of anti-viral therapy on liver fibrosis progression. But we believe that this cohort also highlighted the significant impact of coincidental metabolic syndrome on liver fibrosis progression, which should be less obvious in these patients. Third, some patients might have fluctuating metabolic profile between two visits that we failed to capture. Fourth, given that the natural history of liver fibrosis progression occurs over decades, a follow-up period of close to 4 years may still be too short. Another assessment 10 years from baseline may provide more important information. Lastly, liver steatosis and overweight are commonly considered as confounding factors and independent causes of failed or unreliable LSM. 47 A significant proportion of obese patients, which constituted almost one-fourth of the entire cohort, had significant hepatic steatosis. 29 Luckily, the success rate of LSM remained high at baseline and follow-up visits (89 13% and 94 10% respectively) because of our experienced operators. However, there was still possibility of falsely high values among obese patients even in case of absent or mild fibrosis. 48 In conclusion, coincidental metabolic syndrome increases the risk of liver fibrosis progression in CHB patients, independent viral load and hepatitis activity. Lifestyle modifications should be advised to patients at risk of the metabolic syndrome. AUTHORSHIP Guarantor of the article: None. Author contributions: Grace Wong, Henry Chan and Vincent Wong were responsible for the conception, design of the study and the development of methodology, were responsible for the clinical assessments and treatment monitoring of patients and were responsible for the analysis and interpretation of data, as well as the writing, review and revision of the manuscript. Grace Wong and Vincent Wong performed the liver biopsy. Paul Choi and Anthony Chan performed the histopathological assessment of the liver biopsy specimens. Grace Wong, Zhuo Yu and Angel Chim were responsible for performing transient elastography examination and acquisition of data. Hoi-Yun Chan and Pete Tse were responsible for the virological assays of serum samples. All authors approved the final version of the manuscript. ACKNOWLEDGEMENTS Declaration of personal interests: Grace LH Wong has served as a speaker for Bristol-Myers Squibb, Echosens, Furui and Otsuka, and an advisory board member for Otsuka and Gilead. Henry LY Chan has served as a speaker for Abbott, Bristol-Myers Squibb, Echosens, Gilead, Glaxo-Smith-Kline, Merck, Novartis and Roche, a consultant for Abbott, Bristol-Myers Squibb, Furui, Gilead, Merck, Novartis and Roche, and has received research funding from Roche. Vincent WS Wong has served as a speaker for Bristol-Myers Squibb, Roche, Novartis, Abbott Diagnostics and Echosens, and an advisory board member for Roche, Novartis, Gilead and Otsuka. Declaration of funding interests: This study was funded in part by Research Fund for the Control of Infectious Diseases (RFCID) grant (project reference number: ) to Vincent WS Wong. Aliment Pharmacol Ther 2014; 39:

10 G. L.-H. Wong et al. SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Figure S1. Receiver operating characteristics (ROC) curves of liver stiffness measurements (LSM) for Ishak fibrosis stage (A) 2 (B) 3 (C) bridging fibrosis ( 4) and (D) cirrhosis ( 5). CI, confidence interval. Figure S2. Boxplot of change in different phases of chronic hepatitis B in (A) absolute value and (B) percentage of liver stiffness measurement (LSM). HBeAg, hepatitis B e antigen. Table S1. Clinical characteristics of the patients according to liver fibrosis progression and regression. REFERENCE 1. Chan HL, Sung JJ. Hepatocellular carcinoma and hepatitis B virus. Semin Liver Dis 2006; 26: Chan HL, Tse CH, Mo F, et al. High viral load and hepatitis B virus subgenotype ce are associated with increased risk of hepatocellular carcinoma. J Clin Oncol 2008; 26: Lai CL, Ratziu V, Yuen MF, Poynard T. Viral hepatitis B. Lancet 2003; 362: Wong GL, Chan HL, Chan HY, et al. Accuracy of risk scores for patients with chronic hepatitis B receiving entecavir treatment. Gastroenterology 2013; 144: Wong VW, Chan SL, Mo F, et al. Clinical scoring system to predict hepatocellular carcinoma in chronic hepatitis B carriers. J Clin Oncol 2010; 28: Wong GL, Wong VW, Choi PC, et al. Metabolic syndrome increases the risk of liver cirrhosis in chronic hepatitis B. Gut 2009; 58: Chitturi S, Wong VW, Farrell G. Nonalcoholic fatty liver in Asia: firmly entrenched and rapidly gaining ground. J Gastroenterol Hepatol 2011; 26(Suppl. 1): Wong VW, Wong GL, Yu J, et al. Interaction of adipokines and hepatitis B virus on histological liver injury in the Chinese. Am J Gastroenterol 2010; 105: Wong GL. Transient elastography: kill two birds with one stone? World J Hepatol 2013; 5: Chan HL, Wong GL, Choi PC, et al. Alanine aminotransferase-based algorithms of liver stiffness measurement by transient elastography (Fibroscan) for liver fibrosis in chronic hepatitis B. J Viral Hepat 2009; 16: Wong GL, Wong VW, Choi PC, Chan AW, Chan HL. Development of a noninvasive algorithm with transient elastography (Fibroscan) and serum test formula for advanced liver fibrosis in chronic hepatitis B. Aliment Pharmacol Ther 2010; 31: Wong VW, Vergniol J, Wong GL, et al. Diagnosis of fibrosis and cirrhosis using liver stiffness measurement in nonalcoholic fatty liver disease. Hepatology 2010; 51: Wong GL, Wong VW, Choi PC, et al. Evaluation of alanine transaminase and hepatitis B virus DNA to predict liver cirrhosis in hepatitis B e antigen-negative chronic hepatitis B using transient elastography. Am J Gastroenterol 2008; 103: Wong GL, Wong VW, Choi PC, et al. Clinical factors associated with liver stiffness in hepatitis B e antigenpositive chronic hepatitis B patients. Clin Gastroenterol Hepatol 2009; 7: Wong GL, Chan HL, Yu Z, Chan HY, Tse CH, Wong VW. Liver fibrosis progression is uncommon in patients with inactive chronic hepatitis B - a prospective cohort study with paired transient elastography examination. J Gastroenterol Hepatol 2013; 28: Wong GL, Chan HL, Yu Z, Chan HY, Tse CH, Wong VW. Liver fibrosis progression in chronic hepatitis B patients positive for hepatitis B e antigen: a prospective cohort study with paired transient elastography examination. J Gastroenterol Hepatol 2013; 28: WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: Chan HL, Chui AK, Lau WY, et al. Factors associated with viral breakthrough in lamivudine monoprophylaxis of hepatitis B virus recurrence after liver transplantation. J Med Virol 2002; 68: Chan HL, Thompson A, Martinot- Peignoux M, et al. Hepatitis B surface antigen quantification: Why and how to use it in a core group report. J Hepatol 2011; 55: Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005; 112: Wong GL, Wong VW, Choi PC, et al. Assessment of fibrosis by transient elastography compared with liver biopsy and morphometry in chronic liver diseases. Clin Gastroenterol Hepatol 2008; 6: Wong VW, Wong GL, Chan FK. Liver stiffness measurement: simplicity is prerequisite for reliability. Gastroenterology 2013; 144: Wong GL, Wong VW, Choi PC, et al. On-treatment monitoring of liver fibrosis with transient elastography in chronic hepatitis B patients. Antivir Ther 2011; 16: European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of chronic hepatitis B virus infection. J Hepatol 2012; 57: Liaw YF, Kao JH, Piratvisuth T, et al. Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2012 update. Hepatol Int 2012; 6: Lok AS, McMahon BJ. Chronic hepatitis B: update Hepatology 2009; 50: Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995; 22: Yoon H, Lee JG, Yoo JH, et al. Effects of metabolic syndrome on fibrosis in chronic viral hepatitis. Gut Liver 2013; 7: Wong VW, Chu WC, Wong GL, et al. Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using 892 Aliment Pharmacol Ther 2014; 39:

11 Coincidental metabolic syndrome and fibrosis progression in HBV proton-magnetic resonance spectroscopy and transient elastography. Gut 2012; 61: Wong VW, Wong GL, Chu WC, et al. Hepatitis B virus infection and fatty liver in the general population. J Hepatol 2012; 56: Rubbia-Brandt L, Fabris P, Paganin S, et al. Steatosis affects chronic hepatitis C progression in a genotype specific way. Gut 2004; 53: Cheng YL, Wang YJ, Kao WY, et al. Inverse association between hepatitis B virus infection and fatty liver disease: a large-scale study in populations seeking for check-up. PLoS ONE 2013; 8: e Minakari M, Molaei M, Shalmani HM, et al. Liver steatosis in patients with chronic hepatitis B infection: host and viral risk factors. Eur J Gastroenterol Hepatol 2009; 21: Sebastiani G, Tempesta D, Alberti A. Hepatic iron overload is common in chronic hepatitis B and is more severe in patients coinfected with hepatitis D virus. J Viral Hepat 2012; 19: e Thomopoulos KC, Arvaniti V, Tsamantas AC, et al. Prevalence of liver steatosis in patients with chronic hepatitis B: a study of associated factors and of relationship with fibrosis. Eur J Gastroenterol Hepatol 2006; 18: Paradis V, Perlemuter G, Bonvoust F, et al. High glucose and hyperinsulinemia stimulate connective tissue growth factor expression: a potential mechanism involved in progression to fibrosis in nonalcoholic steatohepatitis. Hepatology 2001; 34(4 Pt 1): Chao LT, Wu CF, Sung FY, et al. Insulin, glucose and hepatocellular carcinoma risk in male hepatitis B carriers: results from 17-year follow-up of a population-based cohort. Carcinogenesis 2011; 32: Zhao J, Zhao Y, Wang H, Gu X, Ji J, Gao C. Association between metabolic abnormalities and HBV related hepatocelluar carcinoma in Chinese: a cross-sectional study. Nutr J 2011; 10: Marcellin P, Gane E, Buti M, et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year open-label follow-up study. Lancet 2013; 381: Ko GT, Tang JS. Metabolic syndrome in the Hong Kong community: the United Christian Nethersole Community Health Service primary healthcare programme Singapore Med J 2007; 48: Nestel P, Lyu R, Low LP, et al. Metabolic syndrome: recent prevalence in East and Southeast Asian populations. Asia Pac J Clin Nutr 2007; 16: Surgeon General s report on physical activity and health. From the Centers for Disease Control and Prevention. JAMA 1996; 276: Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: i xii, Summers LK, Fielding BA, Bradshaw HA, et al. Substituting dietary saturated fat with polyunsaturated fat changes abdominal fat distribution and improves insulin sensitivity. Diabetologia 2002; 45: Vessby B, Uusitupa M, Hermansen K, et al. Substituting dietary saturated for monounsaturated fat impairs insulin sensitivity in healthy men and women: the KANWU Study. Diabetologia 2001; 44: Wong VW, Chan RS, Wong GL, et al. Community-based lifestyle modification programme for non-alcoholic fatty liver disease: a randomized controlled trial. J Hepatol 2013; 59: Wong GL, Wong VW, Chim AM, et al. Factors associated with unreliable liver stiffness measurement and its failure with transient elastography in the Chinese population. J Gastroenterol Hepatol 2011; 26: Wong GL, Chan HL, Choi PC, et al. Association between anthropometric parameters and measurements of liver stiffness by transient elastography. Clin Gastroenterol Hepatol 2013; 11: e1-3. Aliment Pharmacol Ther 2014; 39: