Diagnostic Accuracy of Serological Markers in Viral Hepatitis and Non Alcoholic Fatty Liver Disease Diagnostic Accuracy of Serological Markers in Viral Hepatitis and Non Alcoholic Fatty Liver Disease. A Comparative Study in Tertiary Care Hospital of Weste

Background:  Liver diseases is apparently increasing and emerging as a major public health problem. Worldwide,  chronic hepatitis B has  become  the tenth leading cause of death  and  persons infected with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV), are about 350 million and  125 million respectively. The aim of current retrospective comparative study was concerned primarily to evaluate the significance of non invasive serological markers for diagnosing liver diseases and their predictive implications in Pokhara valley. Materials and Methods:  It was a hospital based retrospective study carried out using the data maintained in the Department of Biochemistry of the Manipal Teaching Hospital, Pokhara, Nepal between 1 st June 2009 and 31 st   October 2010.  The variables collected were total protein, albumin, AST, ALT, total bilirubin, direct bilirubin.  Descriptive statistics and testing of hypothesis were used for the analysis. Data was analyzed using EPI INFO and SPSS 16 software. Results:  Of 515 subjects, 120 were suffering from viral hepatitis and 88 had non alcoholic fatty liver disease. In cases of viral hepatitis, mean values of AST (CI 730.65 to 902.68) and ALT (CI 648.14 to 847.59) were markedly increased as compared to controls. Mild to moderate elevations in serum levels of aspartate aminotransferase (CI 43.42 to 49.49), alanine aminotransferase (CI 43.90 to 53.92) were the most common laboratory abnormalities found in patients with nonalcoholic fatty liver disease. Conclusion:  Non invasive tests have demonstrated a reasonable ability to identify significant fibrosis, cirrhosis in particular, nor is it surprising that liver disease specialists and patients favour a non invasive approach. Key words: Viral hepatitis; Nonalcoholic fatty liver disease; Nepal. DOI: http://dx.doi.org/10.3126/nje.v1i2.5137 Nepal Journal of Epidemiology 2011;1 (2):60-63


Background
Liver diseases is apparently increasing and emerging as a major public health problem.Worldwide, chronic hepatitis B has become the tenth leading cause of death and persons infected with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV), are about 350 million and 125 million respectively 1 .
High-risk sexual and drug use behaviour is most commonly associated with wild spread of hepatitis B and C particularly and about 2.7 million persons are chronically infected with HCV in USA.HCV accounts for 20% of cases of acute hepatitis 2 .The important factors responsible for development of cirrhosis and hepatocellular carcinoma with chronic hepatitis are age, extent, severity, duration, frequency and etiology of the hepatic lobular alterations 3 .young adults are more prone to infection of viral hepatitis 4 .In a typical year, the seroprevalence of HBV (0.82%) was much higher than seroprevalence of HCV(0.47%) in Nepal

5
. A large proportion of the world's population is affected with non alcoholic fatty liver disease.The prevalence in general population of NALFD is about 10 to 24 % in various countries and it rises to 57.5% to 74% in obese persons.Non alcoholic fatty liver disease is generally associated with coexisting conditions like hyperlipidemia, type 2 (non-insulin-dependent) diabetes mellitus and obesity and further , it is almost universally allied with diabetic patients who are morbidly obese 6 .Insulin resistance with its multifactorial molecular pathogenesis is the most reproducible factor for the progression of NALFD 7 .Men are affected earlier than women being the prevalence peaks in the fourth and sixth decade for same in NALFD.It appears to be more common in men and it increases with increasing age and after menopause 8 .Aminotrasferase are released into circulation during hepatocyte damage or injury.The aim of current retrospective comparative study was concerned primarily to evaluate the significance of non invasive serological markers for diagnosing liver diseases and their predictive implications in Pokhara valley. .All these laboratory parameters were analysed using Human reagent kits and with the help of semi autoanalyser (Human, Germany).Analysis was done using descriptive statistics and testing of hypothesis.The data was analyzed using Excel 2003, R 2.8.0 Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSS Inc; Chicago, IL, USA) and the EPI Info 3.5.1 Windows Version.The Chi-square test was used to examine the association between different variables.Z-test was used to compare the significance difference between two variables.A p-value of < 0.05 (two-tailed) was used to establish statistical significance.

Inclusion criteria:
Patients with increased aminotransferase levels (greater than 1.5 times normal) for at least six months, presence of anti-HCV and anti-HBV in serum, low to absent alcohol consumption (less than 30 g/day for men and less than 20 g/day for women) with chief complaints related to vomiting, hepatomegaly, jaundice or ascites were included in our study.Exclusion criteria: Patients with history of an alcohol intake of more than 40 g per week , severe cardiac or renal disease, active intravenous drug abuse.patientsreceiving previous treatment with interferon or immunosuppressive agents or were taking medication that could cause steatosis (i.e.salicylates, nonsteroidal anti-inflammatory drugs, corticosteroids, valproic acid, amiodarone, perhexiline maleate) were excluded from the study.Controls: Healthy males and females with normal liver profile.

Results
Of 515 subjects, 120 were suffering from viral hepatitis and 88 had non alcoholic fatty liver disease.Fibrosis, with early stages being confined to the portal tracts, and late stages being frank cirrhosis characterized by architectural disruption of the liver and was vitally important to be diagnosed at this stage.Hepatocyte necrosis and regenerative hyperplasia in viral hepatitis is immune mediated and spread from virally infected to uninfected cells via soluble cytotoxic mediators 16 .The histological changes in hepatitis includes large droplet steatosis, ballooning of malignant hepatocytes, Mallory-Denk bodies, inflammation and pericellular fibrosis 17 .Nonalcoholic fatty liver disease encompasses a wide spectrum of liver damage, ranging from simple steatosis to steatohepatitis, advanced fibrosis, and cirrhosis.The changes in histological pattern for NAFLD includes steatosis (fatty change), lobular inflammation, periportal fibrosis, mallory bodies, nuclear vacuolation, bile ductal proliferation, perivenular and perisinusoidal fibrosis.Our current study revealed that there was mild elevation in serum levels of AST (CI 43.42 to 49.49) and ALT (CI 43.90 to 53.92) in cases of nonalcoholic fatty liver disease and the ratio of AST/ALT was < 1.The mean values of total proteins (7.08 ± SD0.80) and total bilirubin(1.56± SD0.58) did not show much variation as compared to controls.The above results concurred with findings of Angulo et al 6 .The primary metabolic abnormalities leading to lipid accumulation due to alterations in the pathways of uptake, synthesis, degradation, or secretion in hepatic lipid metabolism resulting from insulin resistance.Increased intrahepatic levels of fatty acids, adipocytokines, tumour necrosis factor-α mitochondrial dysfunction, vascular disturbance provide a source of oxidative stress with subsequent lipid peroxidation, cytokine induction.All these factors promote hepatocellular damage, inflammation and progressive liver disease 18 .Liver biopsy remains the gold standard for the evaluation of liver diseases.However, its

Table 1 : Comparison of biochemical parameters in viral hepatitis and controls
(p=0.001).In cases, mean values of AST (CI 730.65 to 902.68) and ALT (CI 648.14 to 847.59) were markedly increased as compared to controls.The mean values of total (CI 3.15 to 5.16) and direct (CI 2.00 to 2.78) bilirubin were markedly raised in cases of viral hepatitis and showed statistical significance as compared to the mean values of total (CI 0.83to 0.86) and direct (CI 0.23to 0.24) bilirubin in Nepal Journal of Epidemiology 2011;1 (2):60-63 Copyright © 2010 INEA Published online by NepJOL-INASP www.nepjol.info/index.php/NJE62 controls respectively.

Table 2 : Comparison of biochemical parameters in non alcoholic fatty liver disease and controls
ALT is derived mainly from cytosol of hepatocytes.AST is derived both from cytosol and mitochondria of hepatocytes.Magnitude and relative elevation of ALT and AST are important for differential diagnosis, implies liver injury or death of hepatocytes.The stage of disease can change over time and most therapeutic interventions are focused on ameliorating severity of disease.Viral hepatitis is caused by filterable infectious agents and is primarily hepatotropic with outstanding clinical manifestations and evidences of liver injury help of serological markers such as ALT, AST, total bilirubin, direct bilirubin, total proteins would in turn prevent progression to hepatic cirrhosis and also, they can be useful before therapeutic decisions or predicting outcomes of disease.Biochemical markers such as AST and ALT are released from damaged hepatocytes into the circulation.