Interpreting Your Biopsy and Lab Results

1. Interpreting Your Biopsy and Lab Results Daniel Reilly Community Education Specialist FactorHealth Management 2/10/09

2. Disclaimer • This presentation is for information and educational purposes only. Nothing in this presentation should be construed or relied upon by any individual attending this presentation as a medical diagnosis or the delivery of medical advice in any way. Participants are advised to speak with their physician directly about their particular medical circumstances and medical information.

3. The Liver Biopsy • Important diagnostic procedure • Gold standard to assess liver damage • Provides useful information • Grade and stage of liver damage • Hemochromatosis • Steatosis • 1/50,000 of liver is removed • Not done on every patient

4. Biopsy Types • Percutaneous: A needle is inserted between the ribs on the right side • Transjugular: A catheter is threaded into the right jugular vein and then guided to the liver • Laparoscopic: Small incisions are made and a devises are inserted under the skin to obtain a liver sample • Surgical: Only done if other surgical needs exist

5. Metavir Scale - Grade • Activity or degree of inflammation • Considered a precursor to fibrosis • Results are given in a scale of 0-4 • 0 = no activity • 1 = mild activity • 2 = moderate activity • 3 = extensive activity • 4 = severe activity

6. Metavir Scale - Stage • Degree of fibrosis (scarring) • Designed for HCV patients • 0 = no scarring • 1 = minimal scarring • 2 = scarring has occurred and extends outside the area in the liver that contains blood vessels • 3 = bridging fibrosis is spreading and connecting to other areas that contain fibrosis • 4 = cirrhosis, or advanced scarring of the liver

7. Knodell Scale – Grade • Histologic Activity Index (HAI) • Four individually assigned numbers make up a single score to assess inflammation • Periportal and/or bridging necrosis 0-10 • Intralobular degeneration 0-4 • Portal inflammation 0-4 • 0 = no inflammation • 1-4 = minimal inflammation • 5-8 = mild inflammation • 9-12 = moderate inflammation • 13-18 = marked inflammation

8. Knodell Scale – Stage • Degree of fibrosis (scarring) • 0 = no scarring • 1 = mild scarring • 2 = moderate scarring • 3 = severe scarring • 4 = extensive scarring (cirrhosis)

9. Laboratory Tests • Results usually given with a reference range • The range indicates what is normal • Each lab has their own normal ranges • Tests that come back out of the normal range are usually given either a “H” or “L” next to the value.

10. Complete Blood Count (CBC) • WBC: White Blood Cells (Leukocytes) (4,500-11,000/cu MM) • Neutrophils (40.0-84.0%) • Lymphocytes (20.0-50.0%) • Monocytes (2.0-11.0%) • Eosinophils (0.0-6.0%) • Basophils (0.0-2.0%) • RBC: Red Blood Cells (Erythrocytes) (4.76-6.09x10(12)/L) • HGB: Hemoglobin (13.9-16.3 g/dl) • HCT: Hematocrit (41.0-53.0%) • PLT: Platelets (150,000-400,000/cu MM)

11. Liver Function Test (LFT) • ALT: Alanine Aminotransferase (SGPT) (0-40IU/L) • AST: Aspartate Aminotransferase (SGOT) (0-37IU/L) • Bilirubin Total: (0.0-1.3mg/dL) • Direct Bilirubin (0.0-0.4mg/dL) • Indirect Bilirubin (0.0-0.9mg/dL) • Alkaline phosphotase: (39-117IU/L) • Albumin: (3.5-5.5g/dL) • Prothombin time: (11-15seconds)

12. Electrolytes Sodium Potassium Chloride Calcium Iron Phosphorus Magnesium Glucose (60-109mh/dL) Lipids (400-800mg/dL) Triglycerides (10-190mg/dL) Cholesterol (150-250mg/dL) Kidney Function Blood urea nitrogen (BUN) (6-23mg/dL) Creatinine (0.6-1.3mg/dL) Uric acid (1.5-8.0mg/dL) Chemistry Panel

13. HCV Genotype • 1-6 • Hundreds of sub-species • Determines length and probability of successful treatment • 75% of US HCV are G1 • 48 weeks • 50/50 SVR rate • G 2&3 • 24 weeks • 80% SVR rate

14. HCV Viral Load • Qualitative HCV RNA PCR: determines if virus is present in the blood • Positive or Negative • Quantitative HCV RNA PCR: determines the amount of virus in 1 ml of blood • <400,000IU/ml (low) • <2,000,000 copies/ml (low) • Can be measured <10 IU/ml • No upper limit

15. HCV Viral Load • No correlation between HCV viral load and the amount of liver damage. • Used to determine if treatment is working. • A 2 log drop in viral load is calculated by removing two zeros off of the end of the number: i.e. 2,000,000 IU/ml becomes 20,000 IU/ml. • Used to determine if SVR is achieved. • Six months after treatment stops, viral load remains undetectable.

16. HIV Co-infection Lab Tests • CD4 (T-cells) • The absolute # will probably decrease during HCV treatment • The % should remain stable • HIV Viral Load • Usually not affected by HCV treatment

17. FibroSure Test • Non-invasive liver biopsy • Looks at markers in the blood to determine amount of liver damage • Not widely used in US yet • Fibrosis stage (Fibro test): • F0 - no fibrosis: 0.00-0.21 • F0-F1: 0.21-0.27 • F1 - portal fibrosis: 0.27-0.31 • F1-F2: 0.31-0.48 • F2 - bridging fibrosis with few septa: 0.48-0.58 • F3 - bridging fibrosis with many septa: 0.58-0.72 • F3-F4: 0.72-0.74 • F4 - cirrhosis: 0.74-1.00 • Activity grade (ActiTest): • A0 - no activity: 0.00-0.17 • A0-A1: 0.17-0.29 • A1 - minimal activity: 0.29-0.36 • A1-A2: 0.36-0.52 • A2 - moderate activity: 0.52-0.60 • A2-A3: 0.60-0.63 • A3 - severe activity: 0.63-1.00

18. Alpha-fetoprotein (AFP) • An antigen produced in the liver of a fetus that can appear in certain diseases of adults, such as liver cancer. • Range: <40micrograms/L

19. In Conclusion • Always get printed copies of your lab work from your healthcare provider. • Ask your healthcare provider if your lab results are available online. • If you do not understand something, ask your doctor for clarification until it is clear to you. • If your physician orders a test that you are not familiar with, ask for an explanation of why the test was ordered and what the test is looking for.