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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.109 no.2 Madrid feb. 2017 



Could viral load combined with indirect serum markers be an option for predicting the degree of liver fibrosis in treatment-naïve chronic hepatitis B patients?


Key words: Hepatitis B. Liver fibrosis. Indirect serum markers. Viral load.


Dear Editor,

In a recent issue of the Revista Española de Enfermedades Digestivas, we read with interest the article by Coskun et al. (1) "The diagnostic value of a globulin/platelet model for evaluating liver fibrosis in chronic hepatitis B patients". However, we wanted to emphasize some points about the article.

Initially, correlations between APGA (aspartate aminotransferase/platelet/gamma glutamyl transferase/alfa fetoprotein), globulin/platelet index or FIB-4 index and fibrosis scores (r = 0.53, r = 0.42 and r = 0.41, respectively, and p < 0.001 for all) were described as a strong correlation by the authors. When interpreting the results of correlation analysis, both the r value and p value must be considered. If there is a statistically significant difference, the closer the r value is to 1 or -1, the correlation is considered to be stronger. Thus, we believe that it would have been better if r values between 0.40 and 0.60 had been defined as a moderate correlation.

Secondly, the scoring systems including indirect serum markers have also been reported to not be associated with significant fibrosis and also to have better accuracy in the diagnosis of cirrhosis rather than significant fibrosis in patients with hepatitis C virus (HCV) infection, rather than HBV infection (2-5). Furthermore, although serum HBV deoxyribonucleic acid (DNA) levels were not evaluated and mentioned in the article, this has been considered as more accurate to predict fibrosis degree than the models in light of the complex natural history of chronic HBV infection (3). Moreover, higher serum HBV DNA levels and also the presence of precore/core promoter HBV variants have been defined as predictors or risk factors of significant liver fibrosis in HBV patients (2,5).

Consequently, we think that better results for predicting the severity of liver fibrosis may be achieved by using serum HBV DNA levels combined with indirect serum markers in treatment-naïve HBV patients, but randomized large-scale studies are required.


Murat Afyon
Gulhane Military Medical Academy Haydarpaşa Teaching Hospital.
Primary Care Inspection.
Clinic of Family Health Center and the Naval Academy.
Tuzla, Istanbul. Turkey



1. Coskun BD, Altinkaya E, Sevinc E, et al. The diagnostic value of a globulin/platelet model for evaluating liver fibrosis in chronic hepatitis B patients. Rev Esp Enferm Dig 2015;107:740-4. DOI: 10.17235/reed.2015.3851/2015.         [ Links ]

2. Praneenararat S, Chamroonkul N, Sripongpun P, et al. HBV DNA level could predict significant liver fibrosis in HBeAg negative chronic hepatitis B patients with biopsy indication. BMC Gastroenterol 2014;14:218. DOI: 10.1186/s12876-014-0218-6.         [ Links ]

3. Ray Kim W, Berg T, Asselah T, et al. Evaluation of APRI and FIB-4 scoring systems for non-invasive assessment of hepatic fibrosis in chronic hepatitis B patients. J Hepatol 2016;64(4):773-80. DOI: 10.1186/j.jhep.2015.11.012.         [ Links ]

4. Yilmaz Y, Yonal O, Kurt R, et al. Noninvasive assessment of liver fibrosis with the aspartate transaminase to platelet ratio index (APRI): Usefulness in patients with chronic liver disease: APRI in chronic liver disease. Hepat Mon 2011;11(2):103-6.         [ Links ]

5. Lapalus M, Laouenan C, Cardoso AC, et al. Precore/core promoter variants to predict significant fibrosis in both HBeAg positive and negative chronic hepatitis B. Liver Int 2015;35(9):2082-9. DOI: 10.1111/liv.12787.         [ Links ]