世卫组织的慢性HBV指南未能检测到一半未接受治疗的埃塞俄

StephenW

WHO chronic HBV guidelines fail to detect half of untreated Ethiopian patients

Aberra H, et al. J Hepatol. 2019;doi:10.1016/j.jhep.2019.01.037.
March 28, 2019

Current WHO guidelines for chronic hepatitis B failed to detect half of the patients in need of treatment in Ethiopia and more than half of those who met eligibility criteria had developed decompensated cirrhosis.

In a study published in Journal of Hepatology, Hanna Aberra from St. Paul’s Hospital Millennium Medical College in Ethiopia, and colleagues wrote that these results imply the need for a revision of the WHO treatment criteria.


“In 2015, the World Health Organization (WHO) published guidelines for the prevention, care and treatment for persons with [chronic HBV], with an emphasis on resource-limited settings,” they wrote. “However, most of the evidence used to develop the WHO guidelines was based on studies from Asia, North America and Western Europe, and little is known about the accuracy and applicability of the WHO treatment criteria in sub-Saharan Africa.”

To evaluate the diagnostic performance of the guidelines, Aberra and colleagues enrolled 1,190 of 1,303 adult patients with chronic HBV who presented at the St. Paul’s Hospital between February 9 and December 14, 2015. The researchers defined chronic HBV as carriage of HBV surface antigen for more than 6 months.

Results showed that 25.2% were eligible for treatment based on EASL 2017 criteria and 15.3% were eligible based on WHO 2015 criteria. While 51.6% of those with decompensated cirrhosis met WHO eligibility, the percentage of eligible patients among those with compensated cirrhosis was much lower at 35.7%.

Of the 153 patients eligible for treatment based on EASL 2017 criteria but excluded from treatment by WHO 2015 guidelines, 48.4% had cirrhosis and 68.6% had significant fibrosis based on transient elastography measurements.

“The challenge in resource-limited settings, where liver biopsies are generally unrealistic and transient elastography too costly, is to find simple and reliable tools to accurately predict significant liver fibrosis,” the researchers wrote. “An ideal tool should be simple, affordable and easy-to-use, and should have a high sensitivity and specificity to detect patients with advanced liver fibrosis.”

When the researchers analyzed aspartate aminotransferase-to-platelet ratio index results, they found that the APRI threshold of 2.0 recommended by WHO failed to identify most patients in need of treatment, with a sensitivity of 8.5% and specificity of 99.3% compared with EASL guidelines.

However, lowering the APRI threshold improved sensitivity without a substantial decrease in specificity. An APRI lower than 1.5 had a sensitivity of 12% and specificity of 98.5%, while APRI lower than 0.5 had a sensitivity of 46.6% and specificity of 94.8%.

“Results from our own cohort suggest that APRI might still be of use, provided that the decision threshold is set lower than the cut-off at 2.0 currently recommended by the WHO,” Aberra and colleagues concluded. “Our results suggest that the WHO guidelines might be unsuitable in an African setting, and that a future revision should take into account local data from real-life CHB cohorts in sub-Saharan Africa.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

StephenW

世卫组织的慢性HBV指南未能检测到一半未接受治疗的埃塞俄比亚患者

Aberra H，et al。 J Hepatol。 2019; DOI：10.1016 / j.jhep.2019.01.037。
2019年3月28日

目前世界卫生组织的慢性乙型肝炎指南未能检测到埃塞俄比亚需要治疗的患者的一半，超过一半符合资格标准的患者患有失代偿性肝硬化。

在埃塞俄比亚圣保罗医院千禧医学院的Hanna Aberra发表在“肝脏病学杂志”上的一项研究中，他和同事写道，这些结果意味着需要修订WHO治疗标准。


他们写道：“2015年，世界卫生组织（WHO）发布了针对[慢性HBV]患者的预防，护理和治疗指南，重点是资源有限的环境。” “但是，用于制定世界卫生组织指南的大部分证据都是基于亚洲，北美和西欧的研究，而对撒哈拉以南非洲世卫组织治疗标准的准确性和适用性知之甚少。”

为了评估指南的诊断性能，Aberra及其同事招募了1,303名成年慢性HBV患者中的1,190名，他们于2015年2月9日至12月14日期间在圣保罗医院就诊。研究人员将慢性HBV确定为携带HBV表面抗原超过6个月。

结果显示，25.2％符合基于EASL 2017标准的治疗，15.3％符合WHO 2015标准。虽然51.6％的失代偿期肝硬化患者符合世界卫生组织的资格，但在患有代偿性肝硬化的患者中，合格患者的百分比低得多，为35.7％。

在符合EASL 2017标准但根据WHO 2015指南排除治疗的153名符合治疗条件的患者中，48.4％患有肝硬化，68.6％患有基于瞬时弹性成像测量的显着纤维化。

研究人员写道：“在资源有限的环境中，肝脏活组织检查通常不切实际且瞬时弹性成本太高，其挑战在于找到简单可靠的工具来准确预测肝纤维化。” “理想的工具应该简单，价格合理且易于使用，并且应具有高灵敏度和特异性，以检测晚期肝纤维化患者。”

当研究人员分析天冬氨酸氨基转移酶与血小板比率结果时，他们发现WHO推荐的APRI阈值2.0未能确定大多数需要治疗的患者，与EASL指南相比，敏感性为8.5％，特异性为99.3％ 。

然而，降低APRI阈值可提高灵敏度而不会显着降低特异性。低于1.5的APRI具有12％的敏感性和98.5％的特异性，而低于0.5的APRI具有46.6％的灵敏度和94.8％的特异性。

“我们自己的队列结果表明，APRI可能仍然有用，前提是决策阈值设定低于世界卫生组织目前推荐的2.0的截止值，”Aberra及其同事总结道。 “我们的研究结果表明，世卫组织指南可能不适合非洲环境，未来的修订应考虑到撒哈拉以南非洲现实CHB队列的当地数据。” -  Talitha Bennett

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