Background: We compared the diagnostic validity of three non-invasive tests of fibrosis: age to platelet index, aspartate transaminase to platelet ratio index and aspartate transaminase to alanine transaminase ratio to histology fibrosis stage among Africans chronically infected with the hepatitis B virus. Methods: Ninety treatment-naive chronic hepatitis B patients were subjected to liver biopsy. Excluded from the study were patients with HCV and HIV co-infection, and significant alcohol consumption. Staging was performed using the Metavir system, whereas AST, ALT, and platelet count were determined using manual methods, within 4 weeks of liver biopsy. Results of fibrosis score and markers of fibrosis were compared using EPI Info 2005 version 3.3.2. Results: The mean age of the study population was 31.8 ± 8.9 years. Fibrosis stages and AAR, API and APRI scores were positively correlated, respective correlation coefficients being 0.48, 0.48 and 0.22 ( p %lt; 0.0001). Their positive predictive values were 52% (AAR), 63% (API) and 54% (APRI), with sensitivities of 60, 11 and 96%, respectively. The diagnostic accuracy of AAR for cirrhosis was 100%. Conclusions: Non-invasive fibrosis markers are not as sensitive for diagnosing significant fibrosis in chronic hepatitis B compared to hepatitis C patients and might have a limited utility for use in hepatitis B endemic populations.
There is no clinically applicable biomarker for surveillance of hepatocellular carcinoma (HCC), because the sensitivity of serum alpha-fetoprotein (AFP) is too low for this purpose. Here, we determined the diagnostic performance of a panel of urinary metabolites of HCC patients from West Africa. Urine samples were collected from Nigerian and Gambian patients recruited on the case-control platform of the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) program. Urinary proton nuclear magnetic resonance ((1) H-NMR) spectroscopy was used to metabolically phenotype 290 subjects: 63 with HCC; 32 with cirrhosis (Cir); 107 with noncirrhotic liver disease (DC); and 88 normal control (NC) healthy volunteers. Urine samples from a further cohort of 463 subjects (141 HCC, 56 Cir, 178 DC, and 88 NC) were analyzed, the results of which validated the initial cohort. The urinary metabotype of patients with HCC was distinct from those with Cir, DC, and NC with areas under the receiver operating characteristic (AUROC) curves of 0.86 (0.78-0.94), 0.93 (0.89-0.97), and 0.89 (0.80-0.98) in the training set and 0.81 (0.73-0.89), 0.96 (0.94-0.99), and 0.90 (0.85-0.96), respectively, in the validation cohort. A urinary metabolite panel, comprising inosine, indole-3-acetate, galactose, and an N-acetylated amino acid (NAA), showed a high sensitivity (86.9% [75.8-94.2]) and specificity (90.3% [74.2-98.0]) in the discrimination of HCC from cirrhosis, a finding that was corroborated in a validation cohort (AUROC: urinary panel = 0.72; AFP = 0.58). Metabolites that were significantly increased in urine of HCC patients, and which correlated with clinical stage of HCC, were NAA, dimethylglycine, 1-methylnicotinamide, methionine, acetylcarnitine, 2-oxoglutarate, choline, and creatine. The urinary metabotyping of this West African cohort identified and validated a metabolite panel that diagnostically outperforms serum AFP.
Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas: diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those setting up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of "cascades" are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.
Hepatitis B virus (HBV) infection causes a spectrum of acute and chronic liver disease ranging from inactive chronic carrier status to progressive chronic hepatitis, culminating in end-stage cirrhosis and liver cancer. In sub-Saharan Africa, HBV infection is endemic and the HBV-related disease burden is high, making HBV a signficant threat to health in the African continent. The European Union-funded Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) project was established in 2011, with the central directive to reduce the incidence of HBV-related liver cancer in West Africa. In this editorial, we outline some of the achievements and challenges of the PROLIFICA platform in West Africa, highlighting the the importance of collaborative studies in Africa.
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