Objectives: to examine the demographic, clinical, and laboratory characteristics of patients with the chronic HBV related to cirrhosis.
Methods: The viral hepatitis clinic in Azadi Teaching Hospital is dealing with all viral hepatitis cases. All patients with liver cirrhosis caused by chronic HBV infection were studied. Demographic, clinical and laboratory information of the patients were retrieved by interviewing and from the case notes of September in 2014 until December in 2016. Child–Turcotte–Pugh (CTP) classification was used to evaluate the prognosis of liver cirrhosis. The results obtained were analyzed by entering the data into a Microsoft Excel spreadsheet. A value of less than 0.05 was considered as statistically significant.
Results: The total number of patients included in the study was 45. The mean age of the patients was 53.73 ± 14.23 years. Thirtysix cases were males and 9 were females. The evaluation of the 45 patients revealed a higher frequency of CTP-A in both male and female sexes. Cirrhotic patients classified as CTP-A (n=30) and B (n=12) were compared by demographic, clinical and laboratory characteristics. Patients classified as CTP-B were significantly associated with older ages. The levels of hemoglobin, WBC, and platelet were lower, but prothrombin time was higher. There were also significant associations with higher total serum bilirubin (TSB), AST, and ALP levels; whereas, significant associations with the lower levels of albumin, and triglyceride was noted in Child’s B. The AST/ALT ratio of 1 or more was significantly associated with CTP-B.
Conclusions: The cirrhotic patients with CTP-B were older, lower weighted, lower hemoglobin level, lower WBC count, lower platelet counts, increased prothrombin time, increased TSB level, decreased serum albumin level, decreased triglyceride level, increased AST level, AST/ALT ratio (≥1), and increased ALP level.
Key words: Cirrhosis; Chronic Hepatitis B; Characteristic
Cirrhotic patients classified as Child’s grade A (n=30) and B (n=12) were compared by age, gender, ethnicity, body mass
Variable |
MEAN ± SD (no = 45) |
|
Age |
53.73 ± 14.23 |
|
Sex |
Male |
36 (80%) |
Female |
9 (20%) |
|
Ethinicity |
Iraqi |
39 (86.7%) |
Syrian |
6 (12.3%) |
|
Weight (kg) |
78.93 ± 14.28 |
|
Height (cm) |
170.74 ± 14.28 |
|
BMI kg/m2 |
27.13 ± 4.23 |
|
Hemoglobin gm/dl |
14.63 ± 1.78 |
|
WBC (mm3) |
5566.0 ± 1613.74 |
|
Platelet count (mm3) |
154355.56 ± 73787.43 |
|
Prothrombin time (second) |
14.91 ± 2.20 |
|
TSB mg/dl |
1.6 ± 0.72 |
|
Albumin gm/dl |
3.22 ± 0.32 |
|
Protein gm/dl |
7.21 ± 0.83 |
|
FBS mg/dl |
96.11 ± 18.45 |
|
Cholesterol mg/dl |
171.16 ± 43.43 |
|
Triglyceride mg/dl |
131.62 ± 67.91 |
|
ALT U/l |
48.18 ± 27.47 |
|
AST U/l |
68.58 ± 36.18 |
|
ALP U/l |
283.1 ± 53.94 |
|
AFP ng/ml |
3.78 ± 4.30 |
|
HBV-DNA viral load IU/ml |
21232.32 ± 32585.13 |
Child-Pugh score |
Male (no=36) no (%) |
Female (no =9) no (%) |
Total (no=45) no (%) |
Grade A |
24 (66.7) |
6 (66.7) |
30 (66.7) |
Grade B |
9 (25.0) |
3 (33.3) |
12 (26.7) |
Grade C |
3 (8.3) |
0 (0.0) |
3 (6.6) |
Parameter |
Child-Pugh A |
Child-Pugh B |
OR (95% CI) |
P value |
|
Age (year) |
49.67 ± 14.44 |
62.75 ± 10.25 |
-13.08 ( -22.3434 to -3.8166) |
0.0068 |
|
Sex |
Male |
26 |
9 |
1.444 (0.225 to 8.799) |
0.687 |
Female |
6 |
3 |
|||
Ethinicity |
Iraqi |
27 |
10 |
0.556 (0.060 to 5.687) |
0.613 |
Syrian |
3 |
2 |
|||
Weight (kg) |
82.33 ± 14.40 |
71.17 ± 10.50 |
11.16 (1.8814 to 20.4386) |
0.0196 |
|
Height (cm) |
172.10 ± 7.88 |
167.45 ± 5.82 |
4.6500 (-0.4385 to 9.7385) |
0.0722 |
|
BMI kg/m2 |
27.8 ± 4.32 |
25.48 ± 3.52 |
2.3200 (-0.5211 to 5.1611) |
0.1067 |
|
Hemoglobin gm/dl |
15.01 ± 1.80 |
13.64 ± 1.49 |
1.3700 (0.1824 to 2.5576) |
0.0249 |
|
WBC (mm3) |
6006.67 ± 1124.85 |
4839.17 ± 2173.18 |
1167.50 (139.8427 to 2195.1573) |
0.027 |
|
Platelet count (mm3) |
187200.0 ± 66401.0 |
89500.0 ± 33006.31 |
97700.0 (56881.9096 to 138518.0904) |
0.0001 |
|
Prothrombin time (second) |
13.8 ± 1.01 |
16.42 ± 1.89 |
-2.6200 (-3.5259 to -1.7141) |
0.0001 |
|
TSB mg/dl |
1.15 ± 0.11 |
2.24 ± 0.19 |
-1.09 (1.1844 to -0.9956) |
0.0001 |
|
Albumin gm/dl |
3.35 ± 0.21 |
3.06 ± 0.22 |
0.29 (0.1431 to 0.4369) |
0.0003 |
|
Protein gm/dl |
7.29 ± 0.93 |
6.92 ± 0.50 |
0.3700 (-0.2058 to 0.9458) |
0.2015 |
|
FBS mg/dl |
97.93 ± 20.11 |
92.75 ± 14.83 |
5.1800 (-7.8026 to 18.1626) |
0.4248 |
|
Cholesterol mg/dl |
178.97 ± 44.68 |
163.58 ± 34.24 |
15.39 (-13.6508 to 44.4308) |
0.2906 |
|
Triglyceride mg/dl |
145.13 ± 73.28 |
98.67 ± 44.09 |
46.46 (0.5244 to 92.3956) |
0.0476 |
|
ALT U/l |
49.73 ± 28.68 |
48.17 ± 26.45 |
1.56 (-17.8275 to 20.9475) |
0.8716 |
|
AST U/l |
60.83 ± 29.90 |
86.42 ± 46.52 |
-25.59 (-49.9312 to -1.2488) |
0.0398 |
|
AST/ALT ratio (≥1) |
1/30 |
6/12 |
29.0 (2.511 to 776.224) |
0.001 |
|
ALP U/l |
191.65 ± 116.51 |
291.0 ± 59.30 |
-99.35 (-171.1196 to -27.5804) |
0.0079 |
|
AFP ng/ml |
3.17 ± 3.70 |
6.05 ± 31.94 |
-2.88 (-14.6454 to 8.8854) |
0.6235 |
|
HBsAg positive |
30/30 |
12/12 |
- |
- |
|
Anti-HBc total positive |
30/30 |
12/12 |
- |
- |
|
HBeAg positive |
5/30 |
0/12 |
Inf (0339 to Inf) |
0.298 |
|
Anti-Hbe positive |
20/30 |
10/12 |
0.40 (0.049 to 2.60) |
0.453 |
|
HBV-DNA viral load IU/ml |
22739.70 ± 32970.62 |
12698.67 ± 27141.20 |
10041.03 (-11687.2887 to 31769.3487) |
0.3559 |
In order to show association between clinico-demographic and laboratory profile with the severity of hepatic cirrhosis, CTP-A was compared with CTP-B. In this study, there was a significant association between the severity of hepatic cirrhosis and the older age (p=0.0068), lower weight (p=0.0196), low hemoglobin (p=0.0249), low WBC (p=0.027), low platelet (p=0.0001), high prothrombin time (p=0.0001), increased TSB (p=0.0001), decreased serum albumin (p=0.0003), decreased triglyceride (p=0.0476), increased AST (p=0.0398), AST/ALT ratio (≥1) (p≥0.001), and increased ALP (p=0079). However, a significant statistical association was not found between the severity of hepatic cirrhosis and sex (p=0.687), ethnicity (p=0.613), FBS (p=0.4248), serum protein (p=0.2015), ALT (p=0.8716), AFP (p=0.6235), HBeAg positivity (p=0.298), anti-HBe positive (p=0.453), and viral load (p=0.3559). Similar to the findings in the present study, van der Plas et al. [15] reported more frequent liver cirrhosis among older age and men gender. Although, there were more severe hepatic cirrhotic men patients in this study, the association was not significant (p=0.687). In the current study, patients with Child–Pugh score B were significantly associated with lower body weight (p=0.0196), which was consistent with the finding of Li et al. [16]. Generally, in this study, patients with higher BMI were linked with higher albumin level and better liver enzymes, which results mild hepatic cirrhosis (Child’s A). Furthermore, it is well known that the muscle mass is decreasing as liver cirrhosis progresses. In over all, the patients were overweight in this study, which was consistent with the finding of BMI of other literatures [17]. In contrast, Li et al. reported that the majority of the patients in their study were either underweight or normal weight (57%) [16]. The discrepancy in the result between this study and other studies can be explained by the higher rate of CTP-A in my study, while higher rate of CTP-B or C in other studies. The hemoglobin, platelet and WBC levels were significantly lower in Child’s B group in comparison to Child’s A in the study population. It is well known that the chronic HBV infection is a recognized factor of pancytopenia in cirrhotic patients [18]. As the severity of hepatic impairment increases, portal hypertension and splenomegaly is increased as well, while thrombopoietin production is decreased, this subsequently results in more severe hematological abnormalities. Our results showed that prothrombin time, and TSB were significantly higher among Child’s B, whereas the value of the albumin was significantly lower. These findings were in agreement with other literatures [19]. Liver is the only organ for synthesis of albumin and thus liver cirrhosis impairs albumin synthesis. Hence, the rate of albumin synthesis is directly lined with Child-Pugh’s score [20]. In this study, serum triglyceride level was significantly lower among Child’s B than Child’s A population (p=0.0476). However, serum cholesterol level did not show association between the two groups. This figure has e.g. been reported by Kwarteng et al. who found serum triglyceride concentration with the lowest level among the chronic symptomatic HBV population, while serum cholesterol levels were unaffected markedly [21]. It is well described that following HBV infection, the secretion of triglycerides by the liver decreases, which subsequently results in steatotic liver condition [22]. In the current study, we found a significantly higher value of AST in Child’s B group than child’s A group (p=0.398); and similarly, the AST/ALT ratio was more than 1 or higher in cirrhotic Child’s B than Child’s A (p=0.001). These figures were in line with other studies [23]. It is well known that as chronic liver disease is getting worse, the AST/ALT ratio is in increasing. Although the exact reason is not clear for this finding; however, it has been suggested that clearance of AST by sinusoidal cells of the liver is decreasing as liver cirrhosis progresses [24]. Furthermore, we found that ALP level was significantly higher among Child’s B than Child’s A group. In contrast to my finding, Das et al. [25] reported that ALP level remains normal in cirrhotic patients. Recent reports documented that the hypoalbuminemia and elevated ALP level in chronic liver disease is associated with poor overall survival. Therefore, the high risk albumin to alkaline phosphatase ratio (AAPR) is associated with poor prognostic feature, which includes CTP-B and C score [26]. In this study, 2 patients died from HCC in CTP-C. It is well known that HCC is the first cause of death among cirrhotic patients [27].
Although the duration of my study was 27 months, the sample size was small. Furthermore, I did not include some important parameters such as HDV co-infection, and GGT level, because these investigations were not available regularly throughout the study periods.
In conclusion, the current study investigated the associations between variables among CTP categories of chronic HBV patients related to liver cirrhosis in Duhok province. The cirrhotic patients with CTP-B were older, lower weighted, lower hemoglobin level, lower WBC count, lower platelet counts, increased pro-thrombin time, increased TSB level, decreased serum albumin level, decreased triglyceride level, increased AST level, AST/ALT ratio (≥1), and increased ALP level. Although no significant association was found between HBV related to cirrhosis and other variables such as viral load, a larger cohort study with extended parameters are warranted to ascertain the association with severity of the hepatic cirrhosis.
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