{"id":25442,"date":"2022-09-28T09:00:00","date_gmt":"2022-09-28T06:00:00","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25442"},"modified":"2022-09-28T14:34:38","modified_gmt":"2022-09-28T11:34:38","slug":"kronik-hepatit-bde-noninvazif-skorlar","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/09\/28\/kronik-hepatit-bde-noninvazif-skorlar\/","title":{"rendered":"Kronik Hepatit B Hastalar\u0131nda Fibrozisi Belirlemede Noninvazif Skorlama Sistemlerinin Yeri"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6)\u2019n\u00fcn 2017 y\u0131l\u0131nda yay\u0131nlanan verilerine g\u00f6re; t\u00fcm d\u00fcnyada 257- 296 milyon ki\u015finin HBsAg (hepatit B y\u00fczey antijeni) ta\u015f\u0131d\u0131\u011f\u0131, bu say\u0131n\u0131n g\u00fcn\u00fcm\u00fczde 300 milyonu ge\u00e7ti\u011fi ve her y\u0131l bu rakama 1.5 milyon yeni infeksiyonun eklendi\u011fi tahmin ediliyor (1). \u00dclkemizde ise 2011 y\u0131l\u0131nda yap\u0131lan epidemiyolojik bir \u00e7al\u0131\u015fmada; \u00fclke genelinde HBsAg prevalans\u0131 %4.57 saptanm\u0131\u015f ve orta endemisite grubunda yer ald\u0131\u011f\u0131m\u0131z vurgulanm\u0131\u015ft\u0131r (2). Hepatit; hepatik inflamasyon sonucu geli\u015fen h\u00fccre nekrozu ve karaci\u011fer hasar\u0131 olarak tan\u0131mlanmaktad\u0131r. Kronik hepatit ise; karaci\u011ferdeki inflamasyonun 6 aydan daha uzun s\u00fcre devam etti\u011fi, etyolojik, klinik ve patolojik a\u00e7\u0131lardan tan\u0131mlanan bir durumdur. Etyolojide \u00e7ok say\u0131da fakt\u00f6r rol oynamakla birlikte, Hepatit B virusu en \u00f6nemli nedenlerinden biridir (3). Kronik hepatit B (KHB) tan\u0131s\u0131 alm\u0131\u015f bireylerde, karaci\u011fer fibrozis ve histolojik aktivite derecesini belirlemek tedavi yakla\u015f\u0131m\u0131 i\u00e7in temel basamakt\u0131r. Karaci\u011fer biyopsisi; karaci\u011fer hastal\u0131klar\u0131n\u0131n tan\u0131s\u0131, evrelendirilmesi, prognozunun tahmin edilmesi ve hastalar\u0131n tedavi kararlar\u0131n\u0131n verilmesinde alt\u0131n standart testtir. Ancak bu y\u00f6ntem; invazif, hastane yat\u0131\u015f\u0131 gerektiren, i\u015flem sonras\u0131 %1-5 aras\u0131nda komplikasyon, %0.1-0.01 aras\u0131nda mortalite riski bulunan ve s\u0131k tekrarlanamayan pahal\u0131 bir y\u00f6ntemdir. Ayr\u0131ca karaci\u011fer biyopsisi t\u00fcm karaci\u011ferin sadece 1\/50 000\u2019ini \u00f6rnekledi\u011finden, karaci\u011ferin b\u00fct\u00fcn\u00fcn\u00fc temsil edememekte ve %20-30\u2019a varan \u00f6rneklem hatalar\u0131 yap\u0131labilmektedir (4). Bu nedenlerden dolay\u0131 son y\u0131llarda karaci\u011fer biyopsisinin yerine ge\u00e7ebilecek, karaci\u011fer fibrozisini g\u00f6steren, evreleme yapabilen, prognozu tahmin edebilecek, noninvazif, kolay, ucuz, tekrarlanabilir, komplikasyon riski olmayan y\u00f6ntemler ara\u015ft\u0131r\u0131lm\u0131\u015ft\u0131r. Baz\u0131 g\u00f6r\u00fcnt\u00fcleme teknikleri ve \u00e7e\u015fitli serum biyokimyasal testlerine dayal\u0131 y\u00f6ntemler geli\u015ftirilmi\u015ftir. DS\u00d6 Mart 2015\u2019te; kaynak k\u0131s\u0131tl\u0131 b\u00f6lgelerde APRI ve FIB-4 gibi sadece iki veya \u00fc\u00e7 laboratuvar testini i\u00e7eren noninvazif y\u00f6ntemleri, anlaml\u0131 fibrozis d\u00fczeyini tespit etmek i\u00e7in \u00f6nermi\u015ftir (5, 6).<\/span><\/p>\n

Bu \u00e7al\u0131\u015fmada, daha \u00f6nce hi\u00e7 tedavi almam\u0131\u015f KHB\u2019li hastalarda karaci\u011fer biyopsisi ile e\u015f zamanl\u0131 olarak aspartat aminotransferaz (AST) – alanin aminotransferaz (ALT) oran\u0131 (\u201cAST ALT ratio – AAR\u201d), AST trombosit oran\u0131 indeksi (\u201cAST platelet ratio index – APRI\u201d), fibrozis 4 skoru (\u201cfibrosis 4 score – FIB-4\u201d), ya\u015f-trombosit indeksi (\u201cage-platelet index – API\u201d), Hui skoru, Lok skoru, G\u00f6teborg \u00dcniversitesi siroz indeksi (\u201cGoteburg University cirrhosis index \u2013 GUCI\u201d) ve siroz diskriminant skoru (\u201cCirrhosis discriminant score -CDS\u201d) hesapland\u0131 ve bu indekslere ait kendi \u201ccut- off\u201d de\u011ferlerimiz hesaplanarak karaci\u011fer biyopsisini \u00f6ng\u00f6rme g\u00fc\u00e7leri de\u011ferlendirildi.\u00a0<\/span><\/p>\n

Y\u00d6NTEMLER<\/h2>\n

\u00c7al\u0131\u015fmaya Mart 2013 – Kas\u0131m 2017 tarihleri aras\u0131nda Ankara \u00dcniversitesi T\u0131p Fak\u00fcltesi Hastaneleri\u2019nin Gastroenteroloji Klinikleri\u2019nde ve 2019-2021 tarihleri aras\u0131nda Ankara \u015eehir Hastanesi Gastroenteroloji Klini\u011fi\u2019nde karaci\u011fer biyopsisi yap\u0131lan naiv (daha \u00f6nce tedavi almam\u0131\u015f) KHB olgular\u0131 dahil edilmi\u015ftir. Nekroinflamasyonun derecelendirilmesi ve fibrozisin evrelerinin s\u0131n\u0131fland\u0131r\u0131lmas\u0131 i\u00e7in karaci\u011fer biyopsi \u00f6rneklerinin histolojik de\u011ferlendirmesi Ishak ve arkada\u015flar\u0131n\u0131n (7) \u00e7al\u0131\u015fmas\u0131na uygun olarak yap\u0131lm\u0131\u015ft\u0131r.<\/p>\n

\u00c7al\u0131\u015fma i\u00e7in, Ankara \u015eehir Hastanesi Etik Kurulu\u2019ndan 27 Nisan 2022 tarih ve E2-22-1704 karar numaras\u0131yla onay al\u0131nm\u0131\u015ft\u0131r. \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/span><\/p>\n

Noninvazif Y\u00f6ntemler<\/h3>\n

Aspartat Aminotransferaz (AST) -Alanin Aminotransferaz (ALT) Oran\u0131 (\u201cAST ALT Ratio – AAR\u201d)<\/i><\/b><\/h5>\n

AAR ilk olarak 1957\u2019de Fernando De Ritis taraf\u0131ndan tan\u0131mlanm\u0131\u015ft\u0131r. S\u00f6z konusu \u00e7al\u0131\u015fmada; kronik hepatit ve kolestatik karaci\u011fer hastal\u0131\u011f\u0131 olan hastalarda AAR\u2019\u0131n genellikle <1.0 oldu\u011fu, siroz geli\u015fiminde ise s\u0131k<\/span>l\u0131kla bu oran\u0131n >1\u2019e y\u00fckseldi\u011fi bildirilmi\u015ftir. AAR a\u015fa\u011f\u0131daki form\u00fcle g\u00f6re hesaplan\u0131r; skorun >1 olmas\u0131n\u0131n belirgin fibrozisi (F5-6) \u00f6ng\u00f6rmektedir (8).\u00a0<\/span><\/p>\n

AAR = AST (U\/lt) \/ALT (U\/lt)<\/p>\n

AST Trombosit Oran\u0131 \u0130ndeksi (\u201cAST Platelet Ratio Index – APRI\u201d)<\/i><\/b><\/h5>\n

Wai ve arkada\u015flar\u0131 (9) taraf\u0131ndan 2003 y\u0131l\u0131nda 192 hepatit C tan\u0131l\u0131 hasta ile yap\u0131lm\u0131\u015f bir \u00e7al\u0131\u015fmad\u0131r. APRI, a\u015fa\u011f\u0131daki form\u00fcle g\u00f6re hesaplan\u0131r; skorun 0.5 olmas\u0131 fibrozisin yoklu\u011funu, >1.5 olmas\u0131 belirgin fibrozisi (F3-4) ve \u22652 olmas\u0131 (F5-6) ileri fibrozisi \u00f6ng\u00f6rmektedir (9, 10).<\/p>\n

APRI = [(AST \/ normal de\u011ferin \u00fcst s\u0131n\u0131r\u0131) \/ trombosit say\u0131s\u0131 (109<\/sup>\/lt) x 100]<\/p>\n

Fibrozis 4 Skoru (FIB-4)\u00a0<\/span><\/i><\/b><\/h5>\n

FIB-4 skoru, a\u015fa\u011f\u0131daki form\u00fcl ile hesaplan\u0131r; skorun 1.45 olmas\u0131 fibrozisin olmad\u0131\u011f\u0131n\u0131 ve >3.25 olmas\u0131 belirgin fibrozisi \u00f6ng\u00f6rmektedir (11, 12).<\/p>\n

FIB-4 = [ya\u015f (y\u0131l) x AST(U\/lt) \/ trombosit say\u0131s\u0131 (109<\/sup>\/lt) x ALT (U\/lt)\u00bd<\/sup><\/span> ]<\/p>\n

Ya\u015f-Trombosit \u0130ndeksi (\u201cAge-Platelet Index \u2013 API\u201d)\u00a0<\/span><\/i><\/b><\/h5>\n

Ya\u015f (y\u0131l) (<30=0 puan; 30-39=1 puan; 40- 49=2 puan; 50-59=3 puan; 60-69, =4 puan; \u2265<\/b><\/span>70=5 puan) ve trombosit say\u0131lar\u0131na (340 x 109<\/sup>\/lt, 0 puan; 280-339 109<\/sup>\/lt, 1 puan; 220-279 109<\/sup>\/lt, 2 puan; 160-219 109<\/sup>\/lt, 3 puan; 100-159 109<\/sup>\/lt, 4 puan; 40-99 109<\/sup>\/lt, 5 puan; <40 109<\/sup>\/lt, 6 puan) g\u00f6re puanlar verilir ve her iki puan\u0131n toplanmas\u0131 ile skor elde edilir; 6 belirgin fibrozisi, <6 de\u011ferleri ise fibrozisin olmad\u0131\u011f\u0131n\u0131 g\u00f6stermektedir (13).<\/p>\n


\nHui Skoru<\/i><\/b><\/h5>\n

Hui skorunun \u00f6zelli\u011fi; v\u00fccut kitle indeksi (\u201cbody mass index – BMI\u201d), trombosit say\u0131s\u0131, serum alb\u00fcmin ve bilirubin gibi ortak klinik ve laboratuvar parametrelerinin bile\u015fimi olmas\u0131d\u0131r. \u00d6zellikle hepatit C hastalar\u0131nda olduk\u00e7a y\u00fcksek duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fc\u011fe sahip bir fibrozis belirteci olmakla birlikte son \u00e7al\u0131\u015fmalarda hepatit B ve hepatit D i\u00e7in de F3 fibrozisinin belirlenmesinde kullan\u0131labilece\u011fi ortaya konulmu\u015ftur. Hui skoru hesaplama form\u00fcl\u00fc a\u015fa\u011f\u0131da verilmi\u015ftir (14).<\/p>\n

Hui skoru = 3.148 + [0.167 x BMI] + [0.088 x serum bilirubin (mg\/dl)] – [0.151 x serum albumin (mg\/dl)] – [0.019 x trombosit (103<\/sup>\/ \u03bcl)]<\/p>\n

Lok Skoru<\/i><\/b><\/h5>\n

Lok skoru, hepatit C deneme (\u201ctrial\u201d) hastalar\u0131n\u0131 kapsayan b\u00fcy\u00fck bir kohort \u00e7al\u0131\u015fmada geli\u015ftirilmi\u015ftir (15). Trombosit, AST, ALT ve INR (\u201cinternational normalized ratio\u201d)\u2019den olu\u015fan form\u00fcl\u00fc a\u015fa\u011f\u0131da verilmi\u015ftir.<\/p>\n

Log odds = \u20135.56 \u2013 [0.0089 x\u00a0 <\/span>trombosit say\u0131s\u0131 (103<\/sup>\/mm3<\/sup>)] + [1.26 x (AST \/ ALT)] + [5.27 x INR]\u00a0<\/span><\/p>\n

Lok = [exp (log odds)] \/ [1 + EXP (log odds)]<\/p>\n


\n<\/i><\/b><\/span>G\u00f6teborg \u00dcniversitesi Siroz \u0130ndeksi (\u201cGoteburg University Cirrhosis Index \u2013 GUCI\u201d)<\/i><\/b><\/h5>\n

AST, PTZ, INR ve trombosit say\u0131lar\u0131n\u0131 kullanarak a\u015fa\u011f\u0131daki form\u00fclle yap\u0131lan bir hesaplamad\u0131r. \u0130slam ve arkada\u015flar\u0131 (16) 2005 y\u0131l\u0131nda 179 hepatit C hastas\u0131 ile yapt\u0131klar\u0131 \u00e7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131na g\u00f6re GUCI skorunun APRI skoruna k\u0131yasla ileri fibrozisi daha iyi tahmin etti\u011fi g\u00f6r\u00fc\u015f\u00fcn\u00fc ortaya atm\u0131\u015ft\u0131r.<\/p>\n

GUCI Skoru = Normal AST x INR x 100\/trombosit say\u0131s\u0131 (\u00d7109<\/sup>\/lt) \u015feklindedir.<\/p>\n

Siroz Diskriminant Skoru (\u201ccirrhosis discriminant score -CDS\u201d)<\/i><\/b><\/h5>\n

A\u015fa\u011f\u0131daki hasta laboratuvar sonu\u00e7lar\u0131 i\u00e7in verilen puanlar\u0131n toplanmas\u0131yla hesaplanan CDS skoru i\u00e7in form\u00fcl a\u015fa\u011f\u0131daki gibidir (17, 18).\u00a0<\/span><\/p>\n

CDS skoru = Trombosit say\u0131s\u0131 + ALT\/AST oran\u0131 + INR\u00a0<\/span><\/p>\n

Trombosit say\u0131s\u0131:<\/b> >340=0; 280-339=1; 220-279=2; 160-219=3; 100-159=4; 40-99=5; <40=6.\u00a0<\/span><\/p>\n

ALT\/AST oran\u0131:<\/b> >1.7=0; 1.2-1.7=1; 0.6-1.19=2; <0.6 =3.\u00a0<\/span><\/p>\n

INR:<\/b> < 1.1=0; 1.1-1.4=1; >1.4=2.<\/p>\n

\u0130statistiksel Analizler<\/h3>\n

Say\u0131sal veriler, ortalama \u00b1 standart sapma; kategorik veriler ise oran olarak ifade edildi. Verilerin normal da\u011f\u0131l\u0131p da\u011f\u0131lmad\u0131\u011f\u0131 Kolmogorov-Smirnov testi kullan\u0131larak de\u011ferlendirildi. Normal da\u011f\u0131l\u0131ma uyan verilerin analizinde t-test; normal da\u011f\u0131l\u0131ma uymayan verilerin kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda ise Mann- Whitney U testi kullan\u0131ld\u0131. Gruplar, say\u0131sal de\u011fi\u015fkenler i\u00e7in Student t testi veya Mann-Whitney U testi kullan\u0131larak; kategorik de\u011fi\u015fkenler ise \u03c7\u00b2<\/p>\n

veya Fisher\u2019\u0131n kesin testi kullan\u0131larak kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131. Her skorun fibrozisi g\u00f6stermedeki do\u011frulu\u011funu g\u00f6stermek i\u00e7in \u201cReceiver Operating Characteristic (ROC)\u201d ve Youden indeksleri (duyarl\u0131l\u0131k + \u00f6zg\u00fcll\u00fck – 1) hesaplanm\u0131\u015ft\u0131r. Karaci\u011fer inflamasyonunun indirekt g\u00f6stergesi olan laboratuvar parametreleri kullan\u0131larak belirlenen noninvazif skorlama sistemlerinin ba\u015far\u0131s\u0131; literat\u00fcrdeki bir \u00e7ok \u00e7al\u0131\u015fmada iki grubu birbirinden ay\u0131rmada en y\u00fcksek duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fc\u011f\u00fcn oldu\u011fu de\u011fer (\u201ccut- off\u201d) \u00fczerinden ROC analizi yap\u0131larak de\u011ferlendirilmi\u015ftir. \u00c7al\u0131\u015fmam\u0131zda da, AUROC (\u201carea under \u2013 receiver operating characteristic\u201d) de\u011feri hesapland\u0131. AUROC de\u011ferinin 1 olmas\u0131 \u201cideal\u201d olarak de\u011ferlendirilirken, AUROC\u2019un 0.5 veya daha k\u00fc\u00e7\u00fck olmas\u0131 testin tan\u0131sal de\u011ferinin olmad\u0131\u011f\u0131n\u0131n g\u00f6stergesi olarak kabul edildi. Tan\u0131 do\u011frulu\u011fu, bu \u00e7al\u0131\u015fmada belirtilen e\u015fik de\u011ferler kullan\u0131larak; duyarl\u0131l\u0131k, \u00f6zg\u00fcll\u00fck, pozitif ve negatif \u00f6ng\u00f6r\u00fc de\u011feri ve \u201codds ratio (OR)\u201d ile de\u011ferlendirildi. AUROC\u2019lar, Hanley-McNeil testleri kullan\u0131larak kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131 (19). Ayr\u0131ca kullan\u0131lan testlerin tan\u0131sal performans\u0131; do\u011fru s\u0131n\u0131fland\u0131rma ve tan\u0131sal olas\u0131l\u0131k oran\u0131 arac\u0131l\u0131\u011f\u0131yla de\u011ferlendirildi. Do\u011fru s\u0131n\u0131fland\u0131rma de\u011feri, de\u011ferlendirilen test taraf\u0131ndan do\u011fru olarak s\u0131n\u0131fland\u0131r\u0131lan hastalar\u0131n y\u00fczdesinin belirlendi\u011fi bir testtir. Tan\u0131sal olas\u0131l\u0131k oran\u0131 i\u00e7in 1< olan de\u011ferler, testin hastal\u0131k durumu olanlar ile olmayanlar aras\u0131nda ayr\u0131m yapmad\u0131\u011f\u0131n\u0131 g\u00f6sterirken; >1\u2019den b\u00fcy\u00fck de\u011ferler ay\u0131rt edici \u00f6zelliklere sahip oldu\u011funu g\u00f6sterir. Verilerin istatistiksel analizi, SPSS (\u201cStatistical Package for the Social Sciences\u201d) versiyon 21.0 program\u0131 (IBM Corp., Armonk, NY, ABD)\u00a0kullan\u0131larak yap\u0131ld\u0131. \u0130statistiksel anlaml\u0131l\u0131k d\u00fczeyi p<\/i><0.05 olarak kabul edildi.<\/p>\n

BULGULAR<\/h2>\n
\"\"<\/a>

Tablo 1.<\/strong>Hastalar\u0131n Bazal Karakteristik ve Laboratuvar Parametreleri<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong> Siroz (\u0130shak Evre 5-6) Hastas\u0131n\u0131n, Siroz Olmayan (\u0130shak Evre 0-1-2-3-4) Hasta ile Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 1.<\/strong><Tablo 2 \u2018ye ait \u015fekil.<\/p><\/div>\n

\"\"<\/a>

Tablo 3.<\/strong> Hafif hepatitli (\u0130shak Evre 0-1-2) hastan\u0131n, \u015fiddetli hepatitli (\u0130shak Evre 3-4-5-6) Hasta ile Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 2.<\/strong><Tablo 3 \u2018e ait \u015fekil.<\/p><\/div>\n

\u00c7al\u0131\u015fmam\u0131za 45 (%28.3) kad\u0131n, 114 (%71.7) erkek olmak \u00fczere toplamda 159 hasta dahil edildi. Hastalar\u0131n ya\u015f ortalamas\u0131 44.53\u00b111.97, v\u00fccut kitle indeksleri 27.14\u00b14.10 kg\/m2<\/sup> olarak saptand\u0131. Hastalar\u0131n AST, ALT, GGT, ALP, albumin, INR, bilirubin, HBV DNA gibi laboratuvar parametrelerine ait de\u011ferler Tablo 1\u2019de verilmi\u015ftir. Ortalama hepatik aktivite indeksi (\u201chepatic activity index \u2013 HAI\u201d) 8.81\u00b13.66 olarak tespit edildi. On (%6.3) hastada \u0130shak fibrozis skoru ileri fibrozis ile uyumlu olarak \u201cevre 5-6\u201d saptan\u0131rken; 94 (%59.1) hastada \u0130shak skoru \u201cerken evre\u201d veya fibrozis yoklu\u011fu ile uyumlu olarak \u201cevre 0-1-2\u201d \u015feklinde saptand\u0131. \u0130shak evrelerine g\u00f6re hasta say\u0131lar\u0131 \u201cevre 0\u2019dan 6\u201dya kadar s\u0131ras\u0131 ile 24 (%15.1), 45 (%28.3), 25 (%15.7), 35 (%22), 20 (%12.6), 8 (%5) ve 2 (%1.3) idi. \u201cEvre 5-6\u201d fibrozisi olan grup ile \u201cevre 0-1-2-3-4\u201d olan grup k\u0131yasland\u0131\u011f\u0131nda, trombosit, albumin say\u0131lar\u0131 belirgin olarak daha d\u00fc\u015f\u00fck saptan\u0131rken; ALT, AST, ALP, GGT ve HBV DNA de\u011ferlerinde istatiksel anlamda fark saptanmad\u0131 (Tablo 1). Sirozu, sirotik olmayan kronik hepatitten ve hafif hepatiti \u015fiddetli kronik hepatitten ay\u0131rt etmek i\u00e7in APRI, FIB-4, AAR, API, CDS, Lok, GUCI, Hui olmak \u00fczere sekiz noninvazif fibrozis belirteci kullan\u0131ld\u0131. Siroz hastalar\u0131n\u0131 siroz olmayan hastalardan ay\u0131rmakta kullan\u0131lan belirte\u00e7lerden FIB-4, APRI, CDS, Lok, GUCI ve Hui 0.7\u2019nin \u00fczerinde AUROC de\u011ferine sahipken bu belirte\u00e7lerin Youden indekse g\u00f6re hesaplanan \u201ccut-off\u201d de\u011ferleri s\u0131ras\u0131yla; >1.85, >0.62, >6, >0.58, >0.52 ve >0.26 olarak saptand\u0131.\u00a0 <\/span>AAR ve API skorlar\u0131n\u0131n ise AUROC de\u011ferleri 0.6\u2019n\u0131n \u00fczerindeyken bu belirte\u00e7lerin \u201ccut- off\u201d de\u011ferleri ise s\u0131ras\u0131yla >0.7 ve >2 idi. Sirozlu hastalar\u0131, siroz olmayan hastalardan ay\u0131rmak i\u00e7in kullan\u0131lan sekiz noninvazif fibrozis belirtecine ait \u201ccut-off\u201d, AUROC, duyarl\u0131l\u0131k, \u00f6zg\u00fcll\u00fck, pozitif \u00f6ng\u00f6r\u00fc de\u011feri, negatif \u00f6ng\u00f6r\u00fc de\u011feri, tan\u0131sal olas\u0131l\u0131k oran\u0131 ve korelasyon katsay\u0131s\u0131 de\u011ferleri Tablo 2\u2019de verilmi\u015ftir. Hasta kohortu; hafif hepatiti, \u015fiddetli hepatitten ay\u0131rmak i\u00e7in kullan\u0131ld\u0131\u011f\u0131nda ise belirte\u00e7lerden FIB-4, APRI, CDS, Lok, GUCI ve Hui skorlar\u0131n\u0131n AUROC de\u011ferleri 0.7\u2019nin \u00fczerinde saptan\u0131rken bu belirte\u00e7lerin \u201ccut- off\u201d de\u011ferleri s\u0131ras\u0131yla >1.2, >0.34, >3, >0.23, >0.49 ve >0.16 olarak saptand\u0131. Yine ayn\u0131 gruplar\u0131 ay\u0131rmada API ve AAR belirte\u00e7lerinin AUROC de\u011ferleri 0.6\u2019n\u0131n \u00fczerindeydi. Hafif hepatiti, \u015fiddetli hepatitten ay\u0131rmak i\u00e7in kullan\u0131lan sekiz noninvazif fibrozis belirtecine ait \u201ccut-off\u201d, AUROC, duyarl\u0131l\u0131k, \u00f6zg\u00fcll\u00fck, pozitif \u00f6ng\u00f6r\u00fc de\u011feri, negative \u00f6ng\u00f6r\u00fc de\u011feri, tan\u0131sal olas\u0131l\u0131k oran\u0131 ve korelasyon katsay\u0131s\u0131 de\u011ferleri Tablo 3\u2019te verilmi\u015ftir. Tablo 2 ve 3\u2019e ait fig\u00fcrler, Fig\u00fcr 1 ve 2 olarak verilmi\u015ftir. Sirozu, siroz olmayan hastadan; hafif hepatiti \u015fiddetli hepatitten ay\u0131rmada kullan\u0131lan GUCI ve Hui noninvazif fibrozis belirte\u00e7leri say\u0131sal olarak di\u011fer t\u00fcm parametrelerden \u00fcst\u00fcnd\u00fc. Siroz olan hastay\u0131 siroz olmayan gruptan ay\u0131r\u0131rken Hanley-McNeal testi kullan\u0131larak yap\u0131lan AUROC de\u011ferlerinin kar\u015f\u0131la\u015ft\u0131rmas\u0131nda ise istatistiksel \u00fcst\u00fcnl\u00fck sadece AAR ve API\u2019ye kar\u015f\u0131 bulunmaktayd\u0131 (p<\/i><0.001, p<\/i><0.001). Hafif hepatiti \u015fiddetli hepatitten ay\u0131rmada saptanan AUROC de\u011ferlerinin Hanley-McNeal testine g\u00f6re de\u011ferlendirmesinde ise GUCI ve Hui belirte\u00e7leri API, AAR ve CDS\u2019ye g\u00f6re istatistiksel olarak daha \u00fcst\u00fcnd\u00fc (p<\/i><0.001, p<\/i><0.012 ve p<\/i><0.04). \u00c7al\u0131\u015fmam\u0131zda test performans\u0131; duyarl\u0131l\u0131k, \u00f6zg\u00fcll\u00fck, pozitif ve negatif \u00f6ng\u00f6r\u00fc de\u011ferleri ve AUROC e\u011frileri gibi geleneksel nicel g\u00f6stergelerle de\u011ferlendirildi. Bu g\u00f6stergeler, bir arada kullan\u0131ld\u0131klar\u0131nda, bir testin ay\u0131rt etme kabiliyetini belirlemede de\u011ferli unsurlard\u0131r. Ancak, hi\u00e7 biri bir testin performans\u0131n\u0131 de\u011ferlendirmek i\u00e7in tek ba\u015f\u0131na yeterli olabilecek nitelikte de\u011fildir. Bu nedenle \u00e7al\u0131\u015fmam\u0131zda, korelasyon katsay\u0131s\u0131 ve tan\u0131sal olas\u0131l\u0131k oran\u0131 arac\u0131l\u0131\u011f\u0131yla tan\u0131sal do\u011frulu\u011fu da de\u011ferlendirdik. Tablo 2 ve 3\u2019te fibrozis belirte\u00e7lerine ait tan\u0131sal do\u011frulama oran\u0131 ve korelasyon katsay\u0131s\u0131 de\u011ferleri verildi. T\u00fcm testlerin tan\u0131sal do\u011frulama oran\u0131 de\u011ferleri 1\u2019in \u00fczerinde saptand\u0131.\u00a0<\/span><\/span><\/p>\n

\u0130RDELEME<\/h2>\n

Kronik hepatit olgular\u0131n\u0131n histopatolojik de\u011ferlendirmesinde s\u0131kl\u0131kla Ishak\u2019\u0131n (7) modifiye histolojik aktivite indeksi derecelendirme ve evrelendirme sistemi kullan\u0131lmaktad\u0131r. Karaci\u011ferde meydana gelen fibrozisin derecesinin belirlenmesinde karaci\u011fer biyopsisi alt\u0131n standart y\u00f6ntem olmakla birlikte, invazif bir i\u015flem olu\u015fu, komplikasyonlar\u0131n\u0131n varl\u0131\u011f\u0131, maliyeti ve histopatolojik de\u011fi\u015fikliklerin parankim i\u00e7indeki heterojen da\u011f\u0131l\u0131m\u0131 sebebiyle \u00e7e\u015fitli alternatif y\u00f6ntemler aranmaktad\u0131r. Son y\u0131llarda karaci\u011fer biyopsisine alternatif olarak \u00e7e\u015fitli biyokimyasal parametreler ve g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemleri fibrozisin derecesini tahmin etmede kullan\u0131lm\u0131\u015ft\u0131r. Karaci\u011ferde fibrozisi g\u00f6stermede kullan\u0131lan invazif olmayan testler direkt ve indirekt olarak iki grupta incelenebilir. Direkt testler; glikoproteinler, tip IV kollajen, hyal\u00fcronik asit, amino-terminal peptid ve prokollajen III, metalloproteinazlar ve metalloproteinazlar\u0131n doku inhibit\u00f6rlerinin serumdaki d\u00fczeylerinin saptanmas\u0131na dayal\u0131 testlerken, invazif testler ise genellikle AST, ALT, trombosit say\u0131s\u0131, INR, ya\u015f, BMI gibi \u00e7e\u015fitli parametrelerin birbirlerine oran\u0131 veya \u00e7e\u015fitli algoritmalara ba\u011fl\u0131 testlerdir (7, 19, 20).<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda kullan\u0131lan sekiz noninvazif fibrozis belirteci de olduk\u00e7a y\u00fcksek \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131\u011fa sahip testlerdir. Ancak toplum k\u00f6kenli validasyonu yap\u0131lmad\u0131\u011f\u0131 i\u00e7in Kafkas \u0131rk\u0131ndan hastalar\u0131n yer ald\u0131\u011f\u0131 \u00e7al\u0131\u015fmam\u0131zda biz kendi \u201ccut- off\u201d de\u011ferlerimizi kulland\u0131k.\u00a0<\/span><\/p>\n

APRI skoru; kronik hepatitli hastalar\u0131n rutin takibinde bak\u0131lan AST ve trombosit say\u0131s\u0131 parametreleriyle fibrozisi tahmin etmek i\u00e7in hesaplanan bir orand\u0131r. Skorlama sistemi ilk kez Wai ve arkada\u015flar\u0131 (9) taraf\u0131ndan hepatit C\u2019li hastalarda kullan\u0131lm\u0131\u015ft\u0131r. S\u00f6z konusu \u00e7al\u0131\u015fmada, fibrozis ve sirozu \u00f6ng\u00f6rmek i\u00e7in yap\u0131lan hesaplamalarda APRI\u2019nin AUROC de\u011feri s\u0131ras\u0131yla 0.80 ve 0.89 olarak saptanm\u0131\u015ft\u0131r. APRI skoru i\u00e7in yap\u0131lan bir meta-analizde, APRI skorunun 0.5\u2019in alt\u0131na d\u00fc\u015ft\u00fc\u011f\u00fc durumlarda, negative \u00f6ng\u00f6r\u00fc de\u011feri ve sirozu d\u0131\u015flama olas\u0131l\u0131\u011f\u0131 artm\u0131\u015f; puanlar 1.5\u2019in \u00fczerine \u00e7\u0131kt\u0131\u011f\u0131nda ise pozitif \u00f6ng\u00f6r\u00fc de\u011feri ve siroz olma olas\u0131l\u0131\u011f\u0131n\u0131n artm\u0131\u015f oldu\u011fu saptanm\u0131\u015ft\u0131r. Bu durum; <0.5 – >1.5 aras\u0131ndaki orta kademe de\u011ferlerin kesin olarak hangi zonda yer ald\u0131\u011f\u0131n\u0131 net olarak a\u00e7\u0131klamaz. AST de\u011ferinin belirgin fibrozisi olmayan ancak hepatik aktivite indeksi artm\u0131\u015f karaci\u011ferlerde y\u00fcksek olmas\u0131 hepatosit mitokondrilerindeki hasar ve AST klirensindeki azalma nedeniyle olabilir. Bunun yan\u0131nda AST ve ALT d\u00fczeylerindeki dalgalanmalar APRI testinin kullan\u0131m\u0131 i\u00e7in s\u0131n\u0131rlama getirmektedir. Bu nedenle, APRI skoru tek ba\u015f\u0131na hastal\u0131\u011f\u0131 d\u0131\u015flamak i\u00e7in yeterince duyarl\u0131 de\u011fildir (21, 22). Korkmaz ve arkada\u015flar\u0131n\u0131n (23) 40 merkezin kat\u0131ld\u0131\u011f\u0131 ve 2520 KHB hastas\u0131n\u0131 kapsayan \u00e7al\u0131\u015fmas\u0131nda, APRI skorunu da kullanm\u0131\u015f olup duyarl\u0131l\u0131k %56.57 ve\u00a0 <\/span>\u00f6zg\u00fcll\u00fck %71.41 olarak saptanm\u0131\u015ft\u0131r; AUROC de\u011feri ise 0.688 olarak hesaplanm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

Kronik hepatitli hastalarda yap\u0131lan di\u011fer \u00e7al\u0131\u015fmalarda bu de\u011ferin 0.65-0.84 aras\u0131nda de\u011fi\u015fti\u011fi g\u00f6r\u00fclm\u00fc\u015ft\u00fcr (11-13, 24). \u00c7al\u0131\u015fmam\u0131zda APRI belirteci i\u00e7in AUROC de\u011feri 0.7 olarak saptanm\u0131\u015f olup di\u011fer \u00e7al\u0131\u015fmalara g\u00f6re ola\u011fan aral\u0131ktad\u0131r. Ancak Hanley-McNeal testinde di\u011fer belirte\u00e7lere g\u00f6re anlaml\u0131 aral\u0131kta saptanmamas\u0131n\u0131n a\u015fa\u011f\u0131daki nedenlerden kaynakland\u0131\u011f\u0131n\u0131 d\u00fc\u015f\u00fcn\u00fcyoruz (10-13, 25): \u00a0<\/span><\/p>\n

    \n
  • \u0130leri fibrozis grubundaki hastalar\u0131m\u0131z\u0131n trombosit de\u011ferlerinin di\u011fer \u00e7al\u0131\u015fmalara g\u00f6re daha y\u00fcksek olmas\u0131,<\/li>\n
  • \u00c7al\u0131\u015fmam\u0131zdaki ileri fibrozisi olan hasta say\u0131s\u0131n\u0131n azl\u0131\u011f\u0131,<\/li>\n
  • HAI de\u011feri y\u00fcksek ancak fibrozis skoru d\u00fc\u015f\u00fck olan hastalarda da ge\u00e7ici AST d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc olabilece\u011fi,\u00a0<\/span><\/li>\n
  • Literat\u00fcrdeki \u00e7al\u0131\u015fmalar\u0131n \u00e7o\u011funun hepatit C ile yap\u0131lm\u0131\u015f olmas\u0131.\u00a0<\/span><\/li>\n<\/ul>\n

    D\u00f6rt parametreye dayal\u0131 olan fibrozis indeksi (FIB-4); AST, ALT d\u00fczeyi, trombosit say\u0131s\u0131 ve olgunun ya\u015f\u0131 kullan\u0131larak hesaplanan bir form\u00fclasyondur (10,11). Bu yakla\u015f\u0131m\u0131n temel dayanaklar\u0131; ya\u015f ile birlikte hastal\u0131k s\u00fcresinin ve dolay\u0131s\u0131yla fibrozisin art\u0131\u015f\u0131, AST de\u011ferinin mitokondriyal hasar ve klirensindeki azalmadan dolay\u0131 ALT de\u011ferinden daha fazla y\u00fckseli\u015fi ve periportal fibrozis ile birlikte trombopoetin ve trombosit de\u011ferlerindeki azal\u0131\u015f olarak s\u0131ralanabilir (26). FIB-4 belirteci ilk olarak Sterling ve arkada\u015flar\u0131 (12) taraf\u0131ndan 2006 y\u0131l\u0131nda 868 hastan\u0131n dahil edildi\u011fi insan imm\u00fcn yetmezlik virusu (HIV) ve hepatit C virusu (HCV) koenfeksiyonu sonucu olu\u015fan hepatik fibrozisi de\u011ferlendirmek i\u00e7in uygulanm\u0131\u015f olup 1.45\u2019ten d\u00fc\u015f\u00fck de\u011ferlerde anlaml\u0131 fibrozisi d\u0131\u015flamada, 3.25\u2019ten y\u00fcksek de\u011ferlerde ise anlaml\u0131 fibrozisin varl\u0131\u011f\u0131n\u0131 do\u011frulamada y\u00fcksek \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131\u011fa sahip oldu\u011fu vurgulanm\u0131\u015ft\u0131r.<\/span> Lee ve arkada\u015flar\u0131n\u0131n (27) 2021 y\u0131l\u0131nda yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada; APRI ve FIB-4 skorlar\u0131n\u0131n alkolik olmayan ya\u011fl\u0131 karaci\u011fer hastal\u0131\u011f\u0131 olanlarda ve\u00a0 <\/span>karaci\u011fer ile ilgili mortalite ve morbiditenin risk s\u0131n\u0131flamas\u0131nda, biyopsi ile kar\u015f\u0131la\u015ft\u0131r\u0131labilir performansa sahip oldu\u011fu g\u00f6sterilmi\u015ftir. Solak-Grassie ve arkada\u015flar\u0131n\u0131n (28) 2018 y\u0131l\u0131nda yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada; FIB4 skoru ve \u0130shak HAI skoru aras\u0131nda korelasyon bulunurken (p<\/i>=0.03); \u0130shak fibroz skoru (p<\/i>=0.5) ile korelasyon tespit edilmemi\u015ftir. Liu ve arkada\u015flar\u0131n\u0131n (29) 2021 y\u0131l\u0131nda yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada; FIB-4 skorunun anlaml\u0131 fibrozis i\u00e7in \u201ccut-off\u201d de\u011feri, 2.25 ve daha y\u00fcksek de\u011ferler olarak saptanm\u0131\u015ft\u0131r. Korkmaz ve arkada\u015flar\u0131n\u0131n (23) KHB hastalar\u0131nda yapt\u0131klar\u0131 \u00e7ok merkezli \u00e7al\u0131\u015fmada; FIB-4 ve APRI, fibrozis evresi i\u00e7in en y\u00fcksek tan\u0131 do\u011frulu\u011funa sahip noninvazif model iken; FIB-4 ve API, siroz i\u00e7in en y\u00fcksek tan\u0131sal do\u011frulu\u011fa sahip noninvazif model olarak tespit edilmi\u015ftir. Yine bu \u00e7al\u0131\u015fmada fibrozisi \u00f6ng\u00f6rmede; FIB-4 i\u00e7in >1.19 \u201ccut-off\u201d de\u011feri anlaml\u0131 bulunmu\u015ftur. Wang ve arkada\u015flar\u0131n\u0131n (30) 2020 y\u0131l\u0131nda yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada; karaci\u011ferdeki anlaml\u0131 histolojik de\u011fi\u015fiklikleri \u00f6ng\u00f6rmede FIB-4 i\u00e7in \u201ccut-off\u201d de\u011fer 1.28 olarak saptanm\u0131\u015ft\u0131r. Bizim \u00e7al\u0131\u015fmam\u0131zda, siroz olan hastay\u0131 siroz olmayan hastadan ay\u0131rmada <1.85 \u201ccut-off\u201d de\u011feri; hafif \u015fiddetli fibrozisi \u015fiddetli fibrozisten ay\u0131rmada ise >1.2 \u201ccut-off\u201d de\u011feri, AUROC de\u011ferinin >0.7 olmas\u0131 ko\u015fuluyla anlaml\u0131 d\u00fczey olarak bulundu.\u00a0<\/span><\/span><\/p>\n

    Literat\u00fcrde, AAR de\u011ferinin fibrozisi belirlemede APRI de\u011ferine g\u00f6re daha \u00fcst\u00fcn oldu\u011funu g\u00f6steren \u00e7al\u0131\u015fmalar bulunmaktad\u0131r. S\u00f6z konusu \u00e7al\u0131\u015fmalarda, AAR de\u011ferinin \u22651 oldu\u011fu durumlarda belirgin fibrozisi g\u00f6sterme konusunda pozitif \u00f6ng\u00f6r\u00fc de\u011ferinin %90\u2019lara yak\u0131n oldu\u011fu; AAR de\u011ferinin <1 oldu\u011fu durumlarda ise belirgin fibrozisin olmad\u0131\u011f\u0131n\u0131 g\u00f6steren negatif \u00f6ng\u00f6r\u00fc de\u011ferinin %80\u2019lerde oldu\u011fu g\u00f6sterilmi\u015ftir (31).\u00a0 <\/span>Bizim \u00e7al\u0131\u015fmam\u0131zda ise AAR skoru i\u00e7in AUROC de\u011feri her iki grup i\u00e7in s\u0131ras\u0131 ile 0.68 ve 0.69 olarak tespit edildi. AUROC de\u011ferlerindeki bu d\u00fc\u015f\u00fckl\u00fc\u011f\u00fcn sebebinin; KHB hastalar\u0131nda AST ve ALT\u2019nin serum konsantrasyonlar\u0131ndaki sentezlenme, sal\u0131nma, metabolik da\u011f\u0131l\u0131m veya klirenslerindeki de\u011fi\u015fikliklerinden kaynakland\u0131\u011f\u0131n\u0131 d\u00fc\u015f\u00fcnmekteyiz.\u00a0<\/span><\/p>\n

    API; 1997 y\u0131l\u0131nda Poynard ve arkada\u015flar\u0131 (13) taraf\u0131ndan HCV tan\u0131s\u0131 olan 500 hasta \u00fczerine yap\u0131lan \u00e7al\u0131\u015fmada, histolojik lezyonlar\u0131n varl\u0131\u011f\u0131n\u0131 \u00f6ng\u00f6rmek i\u00e7in geli\u015ftirilmi\u015ftir.\u00a0 <\/span>Di\u011fer noninvazif fibrozis belirte\u00e7lerinde oldu\u011fu gibi ya\u015f ile birlikte fibrozisin art\u0131\u015f\u0131 ve b\u00f6ylelikle trombosit say\u0131lar\u0131ndaki d\u00fc\u015f\u00fc\u015f esas\u0131na dayanan bu indeks literat\u00fcrde 0.65-0.78 aras\u0131nda bir\u00e7ok farkl\u0131 AUROC de\u011ferine sahiptir (32). \u00c7al\u0131\u015fmam\u0131zda, 0.64 ve 0.68 olarak iki AU-ROC de\u011ferine sahip olan API de\u011feri literat\u00fcr ile uyumlu bir \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131\u011fa sahip olmakla birlikte Hanley- McNeal testi ile de\u011ferlendirildi\u011finde di\u011fer hi\u00e7bir belirtece g\u00f6re anlaml\u0131 d\u00fczeyde \u00fcst\u00fcn olarak saptanmad\u0131.\u00a0<\/span><\/span><\/p>\n

    Ho ve arkada\u015flar\u0131 (18) taraf\u0131ndan yap\u0131lan bir \u00e7al\u0131\u015fmada, hepatosel\u00fcler kanserli (\u201chepatocellular carcinoma \u2013 HCC\u201d) hastalarda karaci\u011fer fibrozisinin olduk\u00e7a duyarl\u0131 bir belirteci olarak belirtilen CDS skoru, 0.72 AUROC de\u011feri ile Lok ve GUCI indekslerinden anlaml\u0131 d\u00fczeyde daha \u00fcst\u00fcn olarak bulunmu\u015ftur. \u00c7al\u0131\u015fmam\u0131zda CDS indeksinin AUROC de\u011feri 0.7\u2019nin \u00fczerinde olup literat\u00fcr ile benzer oranda \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131\u011fa sahip oldu\u011fu g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Ancak literat\u00fcrden farkl\u0131 olarak yap\u0131lan Hanley-McNeal testinde CDS indeksinin anlaml\u0131 olarak hi\u00e7 bir \u00fcst\u00fcnl\u00fc\u011f\u00fcn\u00fcn olmad\u0131\u011f\u0131 saptanm\u0131\u015ft\u0131r.<\/p>\n

    Literat\u00fcrde Lok indeksi ile yap\u0131lan \u00e7al\u0131\u015fma say\u0131s\u0131 k\u0131s\u0131tl\u0131 olup daha \u00e7ok kronik hepatit C hastalar\u0131nda kullan\u0131ld\u0131\u011f\u0131 g\u00f6r\u00fclm\u00fc\u015ft\u00fcr (15). Bu \u00e7al\u0131\u015fmalarda AUROC de\u011ferleri genellikle 0.75 – 0.85 aras\u0131ndad\u0131r. Lok belirtecine ait \u00e7al\u0131\u015fmam\u0131zdaki AUROC de\u011ferleri de 0.74 – 0.80 de\u011ferleri aras\u0131nda olup literat\u00fcr ile uyumlu olmakla birlikte di\u011fer belirte\u00e7lerde oldu\u011fu gibi Hanley-McNeal testinde de anlaml\u0131 \u00fcst\u00fcnl\u00fc\u011f\u00fc saptanmam\u0131\u015ft\u0131r (33, 34).<\/p>\n

    Zhang ve arkada\u015flar\u0131n\u0131n (35) 2004-2010 y\u0131llar\u0131 aras\u0131nda hepatit B\u2019ye ba\u011fl\u0131 HCC geli\u015fen hastalarda yapt\u0131\u011f\u0131 \u00e7al\u0131\u015fmada, GUCI indeksi i\u00e7in AUROC de\u011feri 0.7 olarak saptanm\u0131\u015f olup bu de\u011fer \u00f6zellikle ileri evre HCC geli\u015fen siroz hastalar\u0131n\u0131 predikte etmekte olduk\u00e7a ba\u015far\u0131l\u0131 bulunmu\u015ftur.<\/p>\n

    Dong ve arkada\u015flar\u0131n\u0131n (36) 536 tedavi almam\u0131\u015f ve 236 tedavi alm\u0131\u015f hastan\u0131n yer ald\u0131\u011f\u0131 \u00e7al\u0131\u015fmas\u0131nda, fibrosis skorlar\u0131n\u0131 belirlemede GUCI skoru i\u00e7in AUROC de\u011feri 0.76 olarak saptanm\u0131\u015ft\u0131r. Otuz noninvazif skorun de\u011ferlendirildi\u011fi bu \u00e7al\u0131\u015fmada, AUROC de\u011ferlerindeki y\u00fcksekliklere ra\u011fmen noninvazif skorlar\u0131n hi\u00e7 birinin fibrosis evrelerini belirlemede tek ba\u015flar\u0131na kullan\u0131lamayaca\u011f\u0131 vurgulanm\u0131\u015ft\u0131r.<\/p>\n

    Literat\u00fcre g\u00f6re, gerek Hui gerekse GUCI skorlar\u0131 tedavi almam\u0131\u015f yeni tan\u0131l\u0131 hepatit B hastalar\u0131nda yeterince kullan\u0131lm\u0131\u015f de\u011fildir. Her iki skorlama sistemi de daha \u00e7ok kronik hepatit C hastalar\u0131 veya etyoloji ba\u011f\u0131ms\u0131z hepatosel\u00fcler kanser tan\u0131s\u0131 bulunan hastalar\u0131 i\u00e7eren \u00e7al\u0131\u015fmalarda kullan\u0131lm\u0131\u015ft\u0131r (14, 37). Bu ba\u011flamda, GUCI ve Hui belirte\u00e7leri i\u00e7in \u00e7al\u0131\u015fmam\u0131zdaki AUROC de\u011ferleri az say\u0131daki literat\u00fcr \u00e7al\u0131\u015fmas\u0131 ile uyumludur. AUROC de\u011ferleri aras\u0131ndaki fark\u0131n anlaml\u0131l\u0131\u011f\u0131 esas\u0131na dayanan Hanley-McNeal testi, literat\u00fcre yeni yeni girmektedir. Hepatit B hastalar\u0131nda noninvazif skorlar\u0131n de\u011ferlendirildi\u011fi \u00e7al\u0131\u015fmam\u0131z, literat\u00fcrde kendi alan\u0131nda bu testin kullan\u0131ld\u0131\u011f\u0131 ilk \u00e7al\u0131\u015fmad\u0131r. \u00c7al\u0131\u015fmam\u0131zda, Hanley-McNeal testine g\u00f6re; GUCI ve Hui skorlar\u0131 gerek siroz gerek hafif \u015fiddette fibrozis ayr\u0131m\u0131nda \u00f6zellikle AAR ve API belirte\u00e7lerine g\u00f6re anlaml\u0131 d\u00fczeyde \u00fcst\u00fcn bulundu.<\/span><\/p>\n

    Sonu\u00e7 olarak; karaci\u011fer biyopsisine alternatif olarak ara\u015ft\u0131r\u0131lan ve noninvazif y\u00f6ntemlerle ilgili yap\u0131lan \u00e7al\u0131\u015fmalar, son y\u0131llarda artm\u0131\u015f olmakla birlikte yeterli d\u00fczeyde do\u011fruluk derecesine ula\u015f\u0131lamam\u0131\u015ft\u0131r.\u00a0 <\/span>Geli\u015ftirilen y\u00f6ntemlerin geni\u015f hasta kitlelerinde uygulanamamas\u0131, kan tetkiklerinin biyopsi ile ayn\u0131 g\u00fcn al\u0131namamas\u0131, de\u011ferlendirilmede ayn\u0131 fibrozis skorlama sisteminin kullan\u0131lmamas\u0131, kar\u015f\u0131la\u015ft\u0131r\u0131lan biyopsi \u00f6rneklerinin ayn\u0131 yetkinlikte patologlar taraf\u0131ndan de\u011ferlendirilmemesi, \u00e7al\u0131\u015fmalardaki farkl\u0131 etnisiteler ve dolay\u0131s\u0131yla virus genotipinin farkl\u0131 olmas\u0131 sebebiyle hi\u00e7bir noninvazif belirte\u00e7 net olarak standardize edilememi\u015ftir. Bu nedenle genel kan\u0131 bir ka\u00e7 noninvazif belirtecin birlikte veya fibroscan gibi alternatif noninvazif metotlar ile kombine kullan\u0131lmas\u0131d\u0131r. Nitekim \u00e7al\u0131\u015fmam\u0131zda da bir\u00e7ok belirtecin sonu\u00e7lar\u0131 ba\u015far\u0131l\u0131 olmakla birlikte AUROC de\u011ferlerinin birbirlerinden anlaml\u0131 d\u00fczeyde \u00fcst\u00fcnl\u00fcklerinin olmad\u0131\u011f\u0131 saptanm\u0131\u015f ve tek ba\u015flar\u0131na karaci\u011fer biyopsisine alternatif olamayacaklar\u0131 tespit edilmi\u015ftir.\u00a0<\/span><\/span><\/p>\n

    \u00c7al\u0131\u015fmam\u0131z, iki merkezli bir \u00e7al\u0131\u015fma olup tedavi almam\u0131\u015f 159 hepatit B hastas\u0131n\u0131 kapsamaktad\u0131r; bu durum \u00e7al\u0131\u015fmam\u0131z\u0131n do\u011fal k\u0131s\u0131tl\u0131l\u0131\u011f\u0131d\u0131r.\u00a0 <\/span>Bu ba\u011flamda daha \u00e7ok merkezin yer ald\u0131\u011f\u0131 hasta say\u0131n\u0131n daha fazla oldu\u011fu \u00e7al\u0131\u015fmalar\u0131 yapmak literature olduk\u00e7a fayda sa\u011flayacakt\u0131r.<\/p>\n","protected":false},"excerpt":{"rendered":"

    G\u0130R\u0130\u015e D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6)\u2019n\u00fcn 2017 y\u0131l\u0131nda yay\u0131nlanan verilerine g\u00f6re; t\u00fcm d\u00fcnyada 257- 296 milyon ki\u015finin HBsAg (hepatit B y\u00fczey antijeni) ta\u015f\u0131d\u0131\u011f\u0131, bu say\u0131n\u0131n g\u00fcn\u00fcm\u00fczde 300 milyonu ge\u00e7ti\u011fi ve her y\u0131l bu rakama 1.5 milyon yeni infeksiyonun eklendi\u011fi tahmin ediliyor (1). \u00dclkemizde ise 2011 y\u0131l\u0131nda yap\u0131lan epidemiyolojik bir \u00e7al\u0131\u015fmada; \u00fclke genelinde HBsAg prevalans\u0131 %4.57 saptanm\u0131\u015f […]<\/p>\n","protected":false},"author":4,"featured_media":25617,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5505,3121,3328],"class_list":["post-25442","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-fibrozis","tag-karaciger","tag-kronik-hepatit-b"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25442","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=25442"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25442\/revisions"}],"predecessor-version":[{"id":25690,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25442\/revisions\/25690"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/25617"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25442"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25442"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25442"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}