Du 2010 Tp Biomarkers Output

25 janv. 2010

LiverCenter

Biomarkers of Liver Injuryin a World without Gold Standards

Thierry Poynard+

AP-HP Groupe Hospitalier Pitié Salpêtrière,UPMC Liver Center, Université Paris 6, INSERM U680, Biopredictive France

1lundi 25 janvier 2010

25 janv. 2010

Insulin resistance

Alcool consumption

Hepatitis B

Hepatitis C

Hemochromatosis

0 150 300 450 600

No advanced fibrosis Advanced fibrosis

2

Population at risk of liver fibrosis, cirrhosis and hepatocellular carcinoma (Millions)


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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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n=100

n=400.000


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FibroMAX: HCV-HBV-ALD-NAFLD

ActiTest

FibroTest SteatoTest

AshTest

NashTest

FibroMAX

5


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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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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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Haptoglobin

Alpha2Macroglobulin

Apolipoprotein A1

Total Bilirubin

Gamma GT

In Situ In Serum: FibroTest

Imbert-Bismut, Lancet 2001

Liver Injury

Activated Stellate Cells

Fibrotic Matrix


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In Situ events: Fibrosis and serum ApoA1 decrease

Apo A1

Trapping

Down Regulation

Paradis Cell Mol Biol 1996, Paradis Hepatology 1996, Mathurin Hepatology 1996.


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Haptoglobin Hemopexin


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12

Validated Fibrosis and Activity Biomarkers 400.000 prescriptions in 35 countriesUsed by 80% of French Hepatologists, first line

FibroTest ActiTest

Castera J Hepatol 2007


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F0

Pas de Fibrose


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F1

Fibrose minime


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F2

Fibrose modérée


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F3

Fibrose importante


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F4

Fibrose sévère


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Message I: Appropriate methods

• Imperfect Gold Standard

• Spectrum bias

• Analysis of discordances

Bedossa Hepatology 2003, Poynard Clin Chem 2005, Poynard Clin Chem 2007, Poynard GCB 2008


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Message II: Appropriate markers

• Hepatologist: Must

• GP and Screening: Simple

• Industry: Rapid

• Health Authorities: Surrogate Endpoint


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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”

90 %

10 %

Biopsy Biomarker


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N Engl J Med 2001


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Risk of chronic liver disease

Biopsy

If contra-indicationBiomarker


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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%”

50 %50 %Biopsy Biomarker


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Biopsy has the same «Gray Zone»Bedossa Hepatology 2003

25mm Biopsy

F4-F3

25% False Positive

F2-F1

25% False Positive and Negative

F1-F0

25% False Negative


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Fibrosis estimates: Profile C

• “Still risk of severe adverse events for liver biopsy”

• “Biopsy has same limitations for adjacent stages than validated biomarkers: there is no intermediate gray zone”

• “No rational or evidence based for biopsy as first line test”

• “Biopsy still necessary if biomarkers results at high risk of false positive/negative”

10 %

90 %

Biopsy Biomarker


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Chronic Hepatitis B or C

FibroTest ActiTest

Advanced FibrosisSevere Activity

Hepatologist

Fibroscan if FibroTest not applicable

No Advanced FibrosisNo Severe Activity

FibroTest every 2-4 years


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Bedossa Hepatology 2003

AUROC 5 mm = 0.75AUROC 15 mm = 0.82AUROC 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”


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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Poynard et al APT 2007


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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


25 janv. 2010

FibroTest: from blood donors to cirrhotics (n=1,570)

0.00

0.33

0.67

1.00

F0 F1 F2 F3 F4

Fibr

otes

t

BloodDonors

Poynard Clin Chem 2004, Comp Hepatol 200434lundi 25 janvier 2010

25 janv. 2010

• 38 Published Studies

• 7.985 Patients

• Standardized AUROC

• 0.84 (0.83-0.86)

• Advanced Fibrosis

Friedrich Rust et al Gastroenterology 2008, Halfon et al GCB 2008

The best you can obtain with

20mm biopsy is 0.90 Bedossa 2003

FibroTest accuracy for the diagnosis of advanced fibrosis


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FibroTest in Chronic Hepatitis B: 3,303 patients

• Myers, J Hepatol 2003 n=209

• Poynard, Am J Gastro 2005 n=283

• Cales, Hepatology 2005 n=46

• Sebastiani, World J Gastro 2006 n=110

• Coco, JVH 2007 n=93

• Zhao Chines J Pract Int Med 2007 n=123

• Poynard, JVH 2008 n=924

• Ngo, 2008 PlosONE 2008 n=1,300

• Abstracts: Castera, J Hepatol 2006 n=154; Hilleret, J Hepatol 2006 n=184,


25 janv. 2010Kinetics of fibrosis according to baseline stagesIn HBV patients treated with lamivudine 2 years

n=283

F0F1 NS

F2F3F4 P=0.01

0.00

0.25

0.50

0.75

1.00

Baseline 6 mo 12 mo 24 mo

FibroTest-FibroSURE

44 Cirrhosis: 42 (95%) improvement at 24 months; Significant regression (>0.30) in 14/44 (32%)

0.73

0.52

Dienstag et al Gastroenterol 2003. Poynard et al Am J G 2005


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A New simple definition of low risk patients

Ngo PlosONE 2008


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A New simple definition of HBV Inactive Carrier

FibroTest<= 0.27 ActiTest <= 0.29

+

Ngo PlosONE 2008

Viral Load < Log5


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Survival according to definition of inactive carrier based on FibroTest-ActiTest normal values in untreated patients

FibroTest and ActiTest

Survival without complications

Survival without death Overall Survival Survival Paired

Controls**

Normaln=289 100% 100% 100% 99.6 %

(99.5-99.6)

Not normaln=208*

91.2 % (84.2-98.1)

94.7 % (89.7-99.8)

91.2 % (84.2-98.1)

98.4 % (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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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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Analyses of Discordances

• Failures of biopsy

• Failures of FibroTest

• Failures of elastography

Reguev AJG 2003, Poynard Clin Chem 2004, Poynard APT 2007, Coco JVH 2007, Poynard PlosOne 2008

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Discordance 30% between 2 estimates

Reference 25 mm Biopsy Surgical Biopsy


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HCV: Stage transitionsInterferon-Ribavirin: Advanced baseline fibrosis

43

0 %

25 %

50 %

75 %

100 %

Fibrotest Biopsy Fibrotest Biopsy

RegressionStableProgression

SVR n=107 NR n=105

Poynard et al, Hepatology 2003

Low quality biopsy0/15 >= 25mm both7/15 >= 15mm both

Low quality biopsy2/24 >= 25mm both

10/24 >= 15mm both

Discordant Cases


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HCV n=416Mean FibroTest (range 0.00-1.00)

0

0,12

0,24

0,36

0,48

0,60

Control (n=304) SVR (n=70)

Baseline 12mo/EOT 24mo/EOF

Vergniol et al JVH 2009

Slow increase = Sensitivity

Slow decrease = Not related to activity


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HCV n=416Mean Liver Stiffness Measurements (range 0-75 kPa )

0

3

6

9

12

15

Control (n=304)SVR (n=70)

Baseline 12mo/EOT 24mo/EOF

Vergniol et al JVH 2009

Too Early = necro-inflammatory activity

improvement ?

No treatment No increase = Lack of sensitivity ?


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HCV n=92Mean Fibrotest and Actitest

0

0,20

0,40

0,60

0,80

1,00

FibrotestActitest

Baseline 12 weeks 24 weeks 48 weeks

D’Arondel et al JVH 2006

Fibrosis Activity


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HBV: Adefovir TrialIncoherence between Biopsy and Virological results

47

0 %

25 %

50 %

75 %

100 %

Biopsy Biopsy

RegressionStableProgression

Treated PCR NegPlacebo

False Positive Low quality biopsies

Median 11mm

False Negative Low quality biopsies

Median 9mm


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Oliveri WJG 2008


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537 Prospective Cases Same day Biopsy and FibroTestCause 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


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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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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Relapse/Reject n=8

No Relapse/Reject n=15

P<0.001

Before LT 24-72 h 7 days 2 weeks 4 weeks 24 weeks 48 weeks

FibroTest in the follow-up of liver transplanted patients: a pilot study

Hamelet EASL 200852lundi 25 janvier 2010

High Risk False Positive Negative

0/954 (0%)


0/7494 (0%)

FibroTest Global Quality Estimates


0.97%


1.97%

FibroScan (Roulot et al 2008)7.1 kPa 12.6% false positives ?


Classical risk of errors

New risk of errors


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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

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AUROCsFibroTest 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

5 year Prognostic Value of FibroTest versus Biopsy Fibrosis Staging Survival Without HCV Complications

N=537 NGO Clin Chem 2006

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HCV Survival according to FibroTest classes

HBV Survival according to FibroTest classesN=537 NGO Clin Chem 2006


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AST/ALT Risk false positive


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TestNbStudies

NbPatients

Quality Score

FibroTest 33 6,549 60/62

FibroSpect 4 463 30/62

FibroMeter 2 1,041 26/62

ELF 3 1,134 30/62

HepaScore 3 757 25/62

Poynard et al, Advances in Clinical Chemistry, 2008, GCB 2008

Quality of Patented Liver Biomarkers


FibroTest!First Line!

Reference Center FibroScan for!Confirmation !

Biopsy!If discordances!


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FibroMAX: HCV-HBV-ALD-NAFLD

ActiTest

FibroTest SteatoTest

AshTest

NashTest

FibroMAX

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SteatoTest for Steatosis744 patients 140 controls

SteatoTestGGT AUROC=0.66

ALT AUROC=0.61

AUROC=0.80

Poynard Comp Hepatol 2005


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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

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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


F4

F1

F0

France: 12,000,000 at Risk100%

5%

Death 15,000/year0.1%

Test10% F2

F3


Du 2010 Tp Biomarkers Output

Health & Medicine

Transcript of Du 2010 Tp Biomarkers Output