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Du 2010 Tp Biomarkers Output
1. 25 janv. 2010
Biomarkers of Liver Injury
in a World without Gold Standards
Thierry Poynard
+
AP-HP Groupe Hospitalier Pitié Salpêtrière,
UPMC Liver Center, Université Paris 6,
INSERM U680, Biopredictive France
LiverCenter
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2. 25 janv. 2010
Population at risk of liver fibrosis, cirrhosis and
hepatocellular carcinoma (Millions)
No advanced fibrosis Advanced fibrosis
Insulin resistance
Alcool consumption
Hepatitis B
Hepatitis C
Hemochromatosis
0 150 300 450 600
2
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3. 25 janv. 2010
10 years of claims for diagnostic procedures 1993-2003:
Severe Adverse Events and Deaths (French Insurance)
Technic Severe Adverse Events Deaths
ERCP 71 30
Liver Biopsy* 11 5
Ultrasound-Endoscopy 4 2
*1 death /8,000 biopsies if one claim out of 2 deaths
Standard severe adverse events prevalence: 3/1,000
Poynard T. Rev Med Interne 2007
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6. 25 janv. 2010
Anticipated Frequently Asked Questions
• Is the perfect fibrosis biomarker possible? No
• There is a "gray zone" or "inaccurate zone" between intermediate stages? No
• Is FibroTest better than non-patented biomarker?: ALT, Forns, APRI... Yes
• Is liver biopsy still useful? Yes
• Same performance of Fibrotest in HCV, HBV, ALD, NAFLD? Yes
• Similar prognostic value of FibroTest vs biopsy? Yes
• Fibrotest-ActiTest-SteatoTest-NashTest-AshTest better than FibroScan? Yes
• Rational of FibroTest components? Yes
• Are the authors credible due to their possible conflict of interest? Yes
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7. 25 janv. 2010
Rational of FibroTest:
• Alpha 2 macroglobulin: key protein for Collagenase metabolism
• Apolipoprotein A1 key protein for Collagen trapping
• Haptoglobin: key protein for binding Free Hemoglobin oxidant
• Total Bilirubin: specific marker of severe late Fibrosis
• Gamma Glutamyl Transpeptidase: sensitive marker of early Fibrosis
• No transaminases: to prevent inflammatory necrosis confusion (ActiTest)
• Proteomic has blindly proved the major diagnostic value of
• Apolipoprotein A
• Haptoglobin
Imbert Bismut 2001, Langlois 2006, Watanabe 2009
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8. 25 janv. 2010
In Situ In Serum: FibroTest
Liver Injury Alpha2Macroglobulin
Total Bilirubin
Gamma GT
Apolipoprotein A1
Fibrotic Matrix
Activated Stellate Cells
Haptoglobin
Imbert-Bismut, Lancet 2001
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9. 25 janv. 2010
In Situ events: Fibrosis and serum ApoA1 decrease
Trapping
Apo A1 Down
Regulation
Paradis Cell Mol Biol 1996, Paradis Hepatology 1996, Mathurin Hepatology 1996.
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12. 25 janv. 2010
Validated Fibrosis and Activity Biomarkers
400.000 prescriptions in 35 countries
Used by 80% of French Hepatologists, first line
FibroTest ActiTest
Castera J Hepatol 2007
12
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13. 25 janv. 2010
F0
Pas de Fibrose
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14. 25 janv. 2010
F1
Fibrose minime
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19. 25 janv. 2010
Message II: Appropriate markers
• Hepatologist: Must
• GP and Screening: Simple
• Industry: Rapid
• Health Authorities: Surrogate Endpoint
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20. 25 janv. 2010
Fibrosis estimates: Profile A
• “Biopsy is still the gold standard”
• “Biomarkers on the market are not accurate enough”
• “I steel need biopsy for all my patients”
• “Biomarkers only if contra-indications of liver biopsy”
10 %
Biopsy Biomarker
90 %
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21. 25 janv. 2010
N Engl J Med 2001
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22. 25 janv. 2010
Risk of
chronic liver disease
If contra-indication
Biomarker
Biopsy
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23. 25 janv. 2010
Fibrosis estimates: Profile B
• “Too many false positive/false negative for intermediate stages”, “Gray zone”
• “Ok for the next generation of biomarkers when they will demonstrate 90%
AUROCs for bridging fibrosis (F2)”
• “Ok for cirrhosis biomarkers or elastography, as AUROCs = 90%”
Biopsy Biomarker 50 % 50 %
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26. Biopsy has the same «Gray Zone»
Bedossa Hepatology 2003
25mm Biopsy
F4-F3 F2-F1 F1-F0
25% 25% 25%
False Positive
False Positive and Negative False Negative
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27. 25 janv. 2010
Fibrosis estimates: Profile C
• “Still risk of severe adverse events for liver biopsy”
• “Biopsy has same limitations for adjacent stages 10 %
than validated biomarkers: there is no
intermediate gray zone”
• “No rational or evidence based for biopsy as first
line test” 90 %
• “Biopsy still necessary if biomarkers results at
high risk of false positive/negative”
Biopsy Biomarker
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28. 25 janv. 2010
Chronic Hepatitis B or C
FibroTest ActiTest
Fibroscan if FibroTest
not applicable
Advanced Fibrosis No Advanced Fibrosis
Severe Activity No Severe Activity
FibroTest
Hepatologist
every 2-4 years
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30. 25 janv. 2010
AUROC 5 mm = 0.75
AUROC 15 mm = 0.82
AUROC 25 mm = 0.89
“We showed that with 25-mm long
biopsy specimens, only 75% were
scored correctly and 65% for 15-
mm biopsy specimens”
Bedossa Hepatology 2003
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31. 25 janv. 2010
Parkes et al review, J Hepatol 2006:
An illustration of obsolete methodology using imperfect gold standard as a
perfect gold standard
• If the Parkes et al statements and conclusions were applied to 25 mm liver
biopsy, which only scored correctly in 75% using perfect gold standard:
• “The 25 mm liver biopsy have a place in assessment of fibrosis to rule-in or
rule-out fibrosis, but in individual patients cannot differentiate the stages of
fibrosis reliably. “
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32. 25 janv. 2010
Poynard et al APT 2007
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33. 25 janv. 2010
Imperfect Gold Standard: Summary
• Entire liver is the perfect Gold Standard
• Biopsy is an imperfect Gold Standard
• Biopsy 25 mm has 25% false positive/ negative versus entire liver
• Waiting for 90% AUROCs for bridging fibrosis biomarker is a dream in a world
without Gold Standards
Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008
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34. 25 janv. 2010
FibroTest: from blood donors to cirrhotics (n=1,570)
1.00
Fibrotest
0.67
0.33
0.00
Blood
Donors F0 F1 F2 F3 F4
Poynard Clin Chem 2004, Comp Hepatol 2004
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35. 25 janv. 2010
FibroTest accuracy for the diagnosis of advanced fibrosis
• 38 Published Studies
• 7.985 Patients
• Standardized AUROC
• 0.84 (0.83-0.86)
The best you can obtain with
20mm biopsy is 0.90 Bedossa 2003
• Advanced Fibrosis
Friedrich Rust et al Gastroenterology 2008, Halfon et al GCB 2008
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37. Kinetics of fibrosis according to baseline stages 25 janv. 2010
In HBV patients treated with lamivudine 2 years
n=283
FibroTest-FibroSURE
1.00
0.73
0.75 0.52 F2F3F4 P=0.01
0.50
0.25 F0F1 NS
0.00
Baseline 6 mo 12 mo 24 mo
44 Cirrhosis: 42 (95%) improvement at 24 months; Significant regression (>0.30) in 14/44 (32%)
Dienstag et al Gastroenterol 2003. Poynard et al Am J G 2005
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38. 25 janv. 2010
A New simple definition of low risk patients
Ngo PlosONE 2008
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39. 25 janv. 2010
A New simple definition of HBV Inactive Carrier
Viral Load < Log5
+
FibroTest<= 0.27 ActiTest <= 0.29
Ngo PlosONE 2008
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40. 25 janv. 2010
Survival according to definition of inactive carrier based on FibroTest-
ActiTest normal values in untreated patients
FibroTest and Survival without Survival without Survival Paired
Overall Survival
ActiTest complications death Controls**
Normal 99.6 %
100% 100% 100%
n=289 (99.5-99.6)
Not normal 91.2 % 94.7 % 91.2 % 98.4 %
n=208* (84.2-98.1) (89.7-99.8) (84.2-98.1) (97.6-99.1)
Both normal values: FibroTest <=0.27 and ActiTest <=0.29
* Survivals of patients with abnormal FibroTest and ActiTest were lower than those of normal FibroTest and ActiTest
(p<0.005)
** Overall survivals of patients with abnormal FibroTest and ActiTest were lower to those in paired controls (p<0.005)
Ngo PlosONE 2008
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41. 25 janv. 2010
Summary:
FibroTest-ActiTest in patients with chronic hepatitis B
• Similar accuracy than in HCV, validated at baseline, during and after HBV
treatment
• Discordances are also due to biopsy failure in at least 50% of cases
• More sensitive than biopsy
• Same prognostic value than biopsy
• Permitted a better definition of non active carrier
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42. 25 janv. 2010
Analyses of Discordances
Reference 25 mm Biopsy Surgical Biopsy
• Failures of biopsy
• Failures of FibroTest
• Failures of elastography
Discordance 30%
between 2 estimates
Reguev AJG 2003, Poynard Clin Chem 2004, Poynard APT 2007, Coco JVH 2007, Poynard PlosOne 2008
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43. 25 janv. 2010
HCV: Stage transitions
Interferon-Ribavirin: Advanced baseline fibrosis
Low quality biopsy
Discordant Cases 0/15 >= 25mm both
7/15 >= 15mm both
Low quality biopsy
2/24 >= 25mm both
SVR n=107 NR n=105 10/24 >= 15mm both
100 %
75 %
Progression
Stable
50 %
Regression
25 %
0 %
Fibrotest Biopsy Fibrotest Biopsy
Poynard et al, Hepatology 2003
43
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44. 25 janv. 2010
HCV n=416
Mean FibroTest (range 0.00-1.00)
Baseline 12mo/EOT 24mo/EOF
Slow increase = Slow decrease =
Sensitivity Not related to activity
0,60
0,48
0,36
0,24
0,12
Control (n=304) 0
SVR (n=70)
Vergniol et al JVH 2009
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45. 25 janv. 2010
HCV n=416
Mean Liver Stiffness Measurements (range 0-75 kPa )
Baseline 12mo/EOT 24mo/EOF
Too Early =
No treatment No increase =
necro-inflammatory activity
Lack of sensitivity ?
improvement ?
15
12
9
6
3
Control (n=304) 0
SVR (n=70)
Vergniol et al JVH 2009
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46. 25 janv. 2010
HCV n=92
Mean Fibrotest and Actitest
Baseline 12 weeks 24 weeks 48 weeks
Fibrosis Activity 1,00
0,80
0,60
0,40
0,20
Fibrotest 0
Actitest
D’Arondel et al JVH 2006
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49. 25 janv. 2010
537 Prospective Cases Same day Biopsy and FibroTest
Cause of errors in the 154 (29%) cases with discordant results
2% FT-AT vs 18% Biopsy (p<0.001)
Poynard et al, Clin Chem 2004
49
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50. 25 janv. 2010
Bedossa et al, Hepatology 2003
Poynard et al, Clin Chem 2004
Quality of Liver Biopsy:
Pitie experience 1,773 biopsies:
16% > 25mm Median 15 mm
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51. 25 janv. 2010
FibroTest validation in “difficult to diagnose patients”
• HIV-HCV: Myers 2003, Cacoub 2008
• Aged patients: Thabut 2006
• Children: de Ledinghen 2007, Friedrich 2008
• Renal insufficiency: Varaud 2005
• Vasculitis: Cacoub 2006
• Hemophiliac Mahor 2006
• Transplanted
• Kidney: Varaud 2006
• Liver: Hamelet 2008
• Normal ALT Poynard 2006, 2008, Castera 2006
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52. 25 janv. 2010
FibroTest in the follow-up of liver transplanted patients: a pilot study
Relapse/Reject n=8
P<0.001
No Relapse/Reject n=15
Before LT 24-72 h 7 days 2 weeks 4 weeks 24 weeks 48 weeks
Hamelet EASL 2008
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53. FibroTest Global Quality Estimates
High Risk High Risk
False Positive Negative False Positive Negative
0/954 (0%) 0/7494 (0%)
FibroScan (Roulot et al 2008)
7.1 kPa 12.6% false positives ?
High Risk High Risk
False Positive Negative False Positive Negative
0.97% 1.97%
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54. Classical risk of errors
New risk of errors
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55. 25 janv. 2010
Prognostic value
• FibroTest in HCV: Ngo, Clin Chem 2006
• FibroTest in HBV: Ngo, PlosOne 2008
• FibroTest in ALD: Naveau, Hepatology 2008
• FibroTest in Mixed severe cirrhosis: Thabut, AASLD 2007
55
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56. 25 janv. 2010
5 year Prognostic Value of FibroTest versus Biopsy Fibrosis Staging
Survival Without HCV Complications
AUROCs
FibroTest 0.96 vs Biopsy 0.91 P=0.01
Pugh 0.80 P=0.006
APRI 0.82 P=0.03
Forns 0.86 P=0.04
N=537 NGO Clin Chem 2006
56
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57. HCV Survival according to FibroTest classes
N=537 NGO Clin Chem 2006
HBV Survival according to FibroTest classes
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63. 25 janv. 2010
SteatoTest for Steatosis
744 patients 140 controls
GGT AUROC=0.66 SteatoTest AUROC=0.80
ALT AUROC=0.61
Poynard Comp Hepatol 2005
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64. 25 janv. 2010
New concept in liver diseases
• Biomarkers are for Hepatologists
• the HDL-Cholesterol for Cardiologists
• Using biomarkers validated for the frequent chronic liver diseases,
• GP will screen advanced fibrosis for Hepatologists,
• Who have good treatment, at least for HCV and HBV
64
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65. 25 janv. 2010
Summary: Responses to Questions
• Is the perfect fibrosis biomarker possible?
• No as 25 mm has 25% False P/N
• There is a "gray zone" or "inaccurate zone" between intermediate stages?
• No as this is the same for 25 mm biopsy (Spectrum effect)
• Is FibroTest better than non-patented biomarker?: ALT, Forns, APRI...
• Yes higher performance and safety than ALT, Forns, APRI
• Is liver biopsy still useful?
• Yes but when everything else failed
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66. 100% France: 12,000,000 at Risk
F0
F1
10% F2 Test
F3
5% F4
0.1% Death 15,000/year
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