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aMAP Risk Score Predicts HCC Development in Patients With Chronic Hepatitis
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND & AIMS
Hepatocellular carcinoma (HCC) is the leading cause of death in patients with chronic hepatitis. In this international collaboration, we sought to develop a global universal HCC risk score to predict the HCC development for patients with chronic hepatitis.
METHODS
A total of 17,374 patients, comprising 10,578 treated Asian patients with chronic hepatitis B (CHB), 2,510 treated Caucasian patients with CHB, 3,566 treated patients with hepatitis C virus (including 2,489 patients with cirrhosis achieving a sustained virological response) and 720 patients with non-viral hepatitis (NVH) from 11 international prospective observational cohorts or randomised controlled trials, were divided into a training cohort (3,688 Asian patients with CHB) and 9 validation cohorts with different aetiologies and ethnicities (n = 13,686).
RESULTS
We developed an HCC risk score, called the aMAP score (ranging from 0 to 100), that involves only age, male, albumin-bilirubin and platelets. This metric performed excellently in assessing HCC risk not only in patients with hepatitis of different aetiologies, but also in those with different ethnicities (C-index: 0.82-0.87). Cut-off values of 50 and 60 were best for discriminating HCC risk. The 3- or 5-year cumulative incidences of HCC were 0-0.8%, 1.5-4.8%, and 8.1-19.9% in the low- (n = 7,413, 43.6%), medium- (n = 6,529, 38.4%), and high-risk (n = 3,044, 17.9%) groups, respectively. The cut-off value of 50 was associated with a sensitivity of 85.7-100% and a negative predictive value of 99.3-100%. The cut-off value of 60 resulted in a specificity of 56.6-95.8% and a positive predictive value of 6.6-15.7%.
CONCLUSIONS
This objective, simple, reliable risk score based on 5 common parameters accurately predicted HCC development, regardless of aetiology and ethnicity, which could help to establish a risk score-guided HCC surveillance strategy worldwide.
LAY SUMMARY
In this international collaboration, we developed and externally validated a simple, objective and accurate prognostic tool (called the aMAP score), that involves only age, male, albumin-bilirubin and platelets. The aMAP score (ranged from 0 to 100) satisfactorily predicted the risk of hepatocellular carcinoma (HCC) development among over 17,000 patients with viral and non-viral hepatitis from 11 global prospective studies. Our findings show that the aMAP score had excellent discrimination and calibration in assessing the 5-year HCC risk among all the cohorts irrespective of aetiology and ethnicity.
Additional Info
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aMAP Risk Score Predicts Hepatocellular Carcinoma Development in Patients With Chronic Hepatitis
J. Hepatol. 2020 Dec 01;73(6)1368-1378, R Fan, G Papatheodoridis, J Sun, H Innes, H Toyoda, Q Xie, S Mo, V Sypsa, IN Guha, T Kumada, J Niu, G Dalekos, S Yasuda, E Barnes, J Lian, V Suri, R Idilman, ST Barclay, X Dou, T Berg, PC Hayes, JF Flaherty, Y Zhou, Z Zhang, M Buti, SJ Hutchinson, Y Guo, JL Calleja, L Lin, L Zhao, Y Chen, HLA Janssen, C Zhu, L Shi, X Tang, A Gaggar, L Wei, J Jia, WL Irving, PJ Johnson, P Lampertico, J HouFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Hepatocellular carcinoma (HCC) almost invariably develops in the background of chronic hepatitis, but the risk varies greatly among individual patients. Fan and colleagues pooled data from 11 cohorts of mostly patients with treated chronic hepatitis to develop a new HCC risk score, which was built on five component variables, including age, male sex, serum level of albumin, serum level of bilirubin, and blood platelet count. They validated this aMAP score in different cohorts of patients with notably distinct liver diseases and reported the concordance index ranging from 0.82 to 0.87 (95% CI, 0.74–0.97) for predicting 5-year HCC risk. Because the validation cohorts included Asian and European patients with or without chronic viral hepatitis (either B or C), the authors concluded that the aMAP score was accurate to predict the 5-year risk of HCC irrespective of etiology and ethnicity.
The aMAP score probably reflects the accumulated injury of the liver as a major determinant of future HCC risk, given its components that include serum albumin and bilirubin levels (formulated as the previously reported ALBI score), blood platelet count, and presumably age as well. Although the validity of the aMAP score is reasonably demonstrated by the authors, we believe a few caveats warrant attention when applying the score to all patients with any etiology of chronic hepatitis. First, the study population was disproportionately composed of treated patients with viral hepatitis (mainly hepatitis B virus [HBV]), with only 4.1% of the study cohort having non-viral liver disease. Therefore, whether this is the appropriate predictive score for patients with non-viral liver disease requires further investigation. Second, extrapolation to untreated HBV patients cannot be taken for granted given that the risk predictors for HCC development are not the same in untreated versus treated HBV patients. In fact, prior studies have shown that risk scores developed in untreated patients, such as the REACH-B score, do not perform as well as others developed specifically for treated chronic hepatitis B patients, such as PAGE-B, CMAD, or REAL-B. Finally, in the case of patients with chronic hepatitis C virus (HCV) infection, two of the three HCV cohorts were made up entirely of patients with cirrhosis who had attained virologic cure with direct-acting antiviral therapy (DAA). In addition, the third HCV cohort included only patients from Japan who had received either interferon or DAA, but it is unclear if only some or all of these patients have been cured. Therefore, extrapolation to HCV patients without cirrhosis and/or untreated HCV patients require further examination and validation. Factors reflecting liver function (such as total bilirubin and albumin) included in the aMAP score are unlikely to differentiate risk in HCV patients without cirrhosis as well.
In summary, the aMAP provided a new score to assess HCC risk in patients with chronic liver disease using data mostly from treated chronic hepatitis B and post-cure HCV patients with cirrhosis; therefore, generalization and application of this score to untreated patients with chronic hepatitis B, hepatitis C patients without cirrhosis, untreated hepatitis C patients, and patients with non-viral liver disease require additional investigation. It will be more informative for clinicians to clarify how reliably the score performs in these patients.