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Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in

a Tertiary Care Referral Hospital, Duhok, Iraqi Kurdistan

Article · June 2017

DOI: 10.15226/2374-815X/4/5/00199

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Research article Journal of Gastroenterology, Pancreatology & Liver Disorders Open Access

Characteristics of Chronic Hepatitis B Virus

Patients Related Liver Cirrhosis in a Tertiary
Care Referral Hospital, Duhok, Iraqi Kurdistan
Muayad A Merza*
Azadi Teaching Hospital, Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Iraqi
Kurdistan

Received: April 3, 2017; Accepted: May 30 , 2017; Published: June 8, 2017

*Corresponding author:Muayad A Merza, Azadi Teaching Hospital, Department of Internal Medicine, College of Medicine, University of Duhok, Azadi
Hospital Street, Duhuk, Kurdistan, Iraq, Tel: +964-750-4506172; Fax: +964-62-761-8824; E-mail: [email protected]

an advanced liver fibrosis that is usually progressive, irreversible,

Abstract
and the only option for the treatment is liver transplantation in
Background: Chronic hepatitis B virus (HBV) related to liver selected patients. The leading risk factors of liver cirrhosis include
cirrhosis is an advanced liver fibrosis that is usually progressive,
alcohol consumption, non-alcoholic steatohepatitis (NASH),
irreversible, and the only option for the treatment is liver
transplantation in selected patients HBV and hepatitis C virus infections [2]. In Asia, HBV comprises
around 44% cases of liver cirrhosis [1]. There is no precise data
Objectives: to examine the demographic, clinical, and laboratory
about the prevalence of HBV related to cirrhosis in Iraq. On the
characteristics of patients with the chronic HBV related to cirrhosis.
other hand, the prevalence of HBV infection is estimated to be
Methods: The viral hepatitis clinic in Azadi Teaching Hospital is 1.6% in Iraq as a country [3] and 1.79% in Duhok as a province
dealing with all viral hepatitis cases. All patients with liver cirrhosis
caused by chronic HBV infection were studied. Demographic,
[4]. Generally, the development of cirrhosis is insidious and
clinical and laboratory information of the patients were retrieved asymptomatic in more than 80% cases; whereas, the minority
by interviewing and from the case notes of September in 2014 until shows symptoms at the diagnosis [5]. The progression of
December in 2016. Child–Turcotte–Pugh (CTP) classification was used HBV infection into liver cirrhosis is associated with some risk
to evaluate the prognosis of liver cirrhosis. The results obtained were factors. For e.g. increasing age, male gender, alcohol intake, and
analyzed by entering the data into a Microsoft Excel spreadsheet. A
value of less than 0.05 was considered as statistically significant. co-infection with hepatitis C virus (HCV) [6]. There is diversity
in clinical presentations of liver cirrhosis related to hepatitis
Results: The total number of patients included in the study was B infection, ranging from asymptomatic to hepatocellular or
45. The mean age of the patients was 53.73 ± 14.23 years. Thirty-
six cases were males and 9 were females. The evaluation of the 45 portal hypertension manifestations [7]. In cirrhotic patients, the
patients revealed a higher frequency of CTP-A in both male and female severity of liver disease is assessed by the Child–Turcotte–Pugh
sexes. Cirrhotic patients classified as CTP-A (n=30) and B (n=12) were (CTP) score and the model for end stage liver disease (MELD)
compared by demographic, clinical and laboratory characteristics. [8]. Child-Pugh is a commonly used as a scoring system, which is
Patients classified as CTP-B were significantly associated with older
based on calculations of variables including total serum bilirubin
ages. The levels of hemoglobin, WBC, and platelet were lower, but
prothrombin time was higher. There were also significant associations (TSB), serum albumin, international normalized ratio (INR) or
with higher total serum bilirubin (TSB), AST, and ALP levels; whereas, prothrombin time (PT), hepatic encephalopathy, and ascites
significant associations with the lower levels of albumin, and [9]. To the best of our knowledge, this is the first study about
triglyceride was noted in Child’s B. The AST/ALT ratio of 1 or more characteristics of HBV infection related to cirrhosis in Iraq. The
was significantly associated with CTP-B.
present study was aimed to examine the demographic, clinical,
Conclusions: The cirrhotic patients with CTP-B were older, lower and laboratory characteristics of patients with the chronic HBV
weighted, lower hemoglobin level, lower WBC count, lower platelet related to cirrhosis.
counts, increased prothrombin time, increased TSB level, decreased
serum albumin level, decreased triglyceride level, increased AST level, Patients and Methods
AST/ALT ratio (≥1), and increased ALP level.
Setting
Key words: Cirrhosis; Chronic Hepatitis B; Characteristic
The viral hepatitis clinic in Azadi Teaching Hospital
Introduction is dealing with all viral hepatitis cases. The center is designed
Despite the availability of vaccination against hepatitis B to manage viral hepatitis cases. The patients were visiting the
virus (HBV) and antiviral treatment, more than one million deaths center on regular intervals based on their clinical conditions. All
occurred in the world due to liver cirrhosis [1]. Liver cirrhosis is of the patients’ information was collected in standardized case

Symbiosis Group *Corresponding author email: [email protected]

Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Copyright:
Care Referral Hospital, Duhok, Iraqi Kurdistan © 2017 Muayad A Merza

notes. Table 1: Clinico-demogarphic and laboratory profile of chronic

Study design and patients hepatitis B virus patients related liver cirrhosis
Variable MEAN ± SD (no = 45)
The study included all patients of liver cirrhosis caused
by chronic HBV infection. Demographic, clinical and laboratory Age 53.73 ± 14.23
information of the patients were retrieved by interviewing Male 36 (80%)
and from the case notes of September in 2014 until December Sex
Female 9 (20%)
in 2016. Child-Pugh’s classification was used to evaluate the
prognosis of liver cirrhosis (10). The classification has 3 grades. Iraqi 39 (86.7%)
Ethinicity
The study was approved by the ethical research committee, Syrian 6 (12.3%)
College of Medicine, University of Duhok. An informed written
Weight (kg) 78.93 ± 14.28
consent was obtained from all participants in this study. The
inclusion criteria included hepatitis B surface antigen (HBsAg) Height (cm) 170.74 ± 14.28
positive patients, Anti-hepatitis B core antigen antibodies-IgG BMI kg/m2 27.13 ± 4.23
positive with liver cirrhosis. The diagnosis of liver cirrhosis was Hemoglobin gm/dl 14.63 ± 1.78
based on either laboratory findings, clinical findings of portal
WBC (mm3) 5566.0 ± 1613.74
hypertension, imaging findings including ultrasound, endoscopic
features of varices of esophagus or stomach and/or histological Platelet count (mm3) 154355.56 ± 73787.43
findings. All cases of liver cirrhosis due to causes other than HBV Prothrombin time (second) 14.91 ± 2.20
were excluded from the study.
TSB mg/dl 1.6 ± 0.72
Statistical analysis Albumin gm/dl 3.22 ± 0.32
The results obtained were analyzed by entering the data Protein gm/dl 7.21 ± 0.83
into a Microsoft Excel spreadsheet. A value of less than 0.05 was
FBS mg/dl 96.11 ± 18.45
considered as statistically significant.
Cholesterol mg/dl 171.16 ± 43.43
Results
Triglyceride mg/dl 131.62 ± 67.91
The total number of patients included in the study was ALT U/l 48.18 ± 27.47
45. The mean age of the patients was 53.73 ± 14.23 years. Thirty-
AST U/l 68.58 ± 36.18
six cases were males and 9 were females with a male: female
ratio of 4: 1. Baseline characteristics of the study population are ALP U/l 283.1 ± 53.94
demonstrated in table 1. Severity of liver disease on presentation AFP ng/ml 3.78 ± 4.30
was evaluated using Child-Pugh’s score (Figure). The evaluation
of the 45 patients revealed a higher frequency of Child-Pugh’s A HBV-DNA viral load IU/ml 21232.32 ± 32585.13
classification in both male and female sexes, which comprised the
same percentage (66.7%) for both genders (Table 2). Note: BMI = body mass index, WBC = white blood cell, TSB = total serum
bilirubin, FBS = fasting blood sugar, ALT = alanine amino transferase,
Cirrhotic patients classified as Child’s grade A (n=30)
AST = aspartate aminotransferase, ALP = alkaline phosphatase, AFP =
and B (n=12) were compared by age, gender, ethnicity, body mass
alpha-fetoprotein, HBV = hepatitis B virus.

index (BMI), hematological indices, biochemistry parameters,

viral markers, and viral load (Table 3). Patients classified as Child’s
B grade 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 Child’s grade B (Table 3).
Other parameters did not show significant associations. During
the study period, the prognosis of the patients in CTP-A and CTP-B
were good; whereas, the prognosis of the patients in CTP-C were
poor. As a proof, two patients died because of the development of
Figure: Child-Pugh’s classification in studied population hepatocellular carcinoma (HCC).

Citation: Muayad A Merza (2017) Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Care Refer- Page 2 of 5
ral Hospital, Duhok, Iraqi Kurdistan. Gastroenterol Pancreatol Liver Disord. 4(5): 1-5.
DOI: http://dx.doi. org/10.15226/2374-815X/4/5/00199
Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Copyright:
Care Referral Hospital, Duhok, Iraqi Kurdistan © 2017 Muayad A Merza

Table 2: Child-Pugh Classification of chronic hepatitis B virus related cirrhosis

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)

Table 3: Comparison of the characteristics between the 42 patients with Child-Pugh classes A and B
Child-Pugh A Child-Pugh B
Parameter (no=30) (no=12) OR (95% CI) P value
no (%) no (%)
Age (year) 49.67 ± 14.44 62.75 ± 10.25 -13.08 ( -22.3434 to -3.8166) 0.0068
Male 26 9 0.687
Sex 1.444 (0.225 to 8.799)
Female 6 3
Iraqi 27 10 0.613
Ethinicity 0.556 (0.060 to 5.687)
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
1167.50 (139.8427 to
WBC (mm3) 6006.67 ± 1124.85 4839.17 ± 2173.18 0.027
2195.1573)
97700.0 (56881.9096 to
Platelet count (mm3) 187200.0 ± 66401.0 89500.0 ± 33006.31 0.0001
138518.0904)
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
10041.03 (-11687.2887 to
HBV-DNA viral load IU/ml 22739.70 ± 32970.62 12698.67 ± 27141.20 0.3559
31769.3487)

Citation: Muayad A Merza (2017) Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Care Refer- Page 3 of 5
ral Hospital, Duhok, Iraqi Kurdistan. Gastroenterol Pancreatol Liver Disord. 4(5): 1-5.
DOI: http://dx.doi. org/10.15226/2374-815X/4/5/00199
Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Copyright:
Care Referral Hospital, Duhok, Iraqi Kurdistan © 2017 Muayad A Merza

Discussion normal weight (57%) [16]. The discrepancy in the result between
Hepatitis B related to cirrhosis is directly linked with this study and other studies can be explained by the higher rate of
morbidity and mortality in chronic HBV infection. No age exempt CTP-A in my study, while higher rate of CTP-B or C in other stud-
exists for liver cirrhosis in chronic HBV. In this study, the mean ies. The hemoglobin, platelet and WBC levels were significantly
age of the patients was 53.73 ± 14.23 years, which is consistent lower in Child’s B group in comparison to Child’s A in the study
with other literatures that document frequent occurrence of liver population. It is well known that the chronic HBV infection is a
cirrhosis in old patients [11]. In the current study, there were pre- recognized factor of pancytopenia in cirrhotic patients [18]. As
dominance of both male sex (80%) and Iraqi nationality (86.7%). the severity of hepatic impairment increases, portal hypertension
The high rate of male ratio is in parallel with other studies, which and splenomegaly is increased as well, while thrombopoietin pro-
documents a higher rate exposure of men to HBV infection [12]. In duction is decreased, this subsequently results in more severe he-
our previous work in 2016, we studied the prevalence of hepatitis matological abnormalities. Our results showed that prothrombin
B and C in 214 tuberculosis patients. We found that 97.2% were time, and TSB were significantly higher among Child’s B, whereas
Iraqi and 2.8% were mainly Syrian nationality [13]. Perhaps, the the value of the albumin was significantly lower. These findings
high rate of the Syrian patients (12.3%) in the present study has were in agreement with other literatures [19]. Liver is the only
resulted from the fled of the people to Iraqi Kurdistan following organ for synthesis of albumin and thus liver cirrhosis impairs al-
internal conflicts in Syria. In addition, Syria is an intermediate bumin synthesis. Hence, the rate of albumin synthesis is directly
HBV incidence country. In this study, we classified cirrhotic pa- lined with Child-Pugh’s score [20]. In this study, serum triglyc-
tients into three groups according to Child-Pugh’s scoring system eride level was significantly lower among Child’s B than Child’s
[10]. Out of 45 patients, 30 (66.7%), 12 (26.7%), and 3 (6.6%) A population (p=0.0476). However, serum cholesterol level did
patients were graded as Child’s A, B, and C, respectively. The fig- not show association between the two groups. This figure has e.g.
ure was in line with other studies [14]. This can be justified for been reported by Kwarteng et al. who found serum triglyceride
hepatitis B patients as they undergo regular medical follow ups, concentration with the lowest level among the chronic symptom-
which makes earlier detection of liver cirrhosis. In contrast, the atic HBV population, while serum cholesterol levels were unaf-
prevalence of Child’s B is higher in alcoholic cirrhosis than HBV fected markedly [21]. It is well described that following HBV in-
etiology, which may be explained by alcoholic patients as they fection, the secretion of triglycerides by the liver decreases, which
seek medical advices after the appearance of clinical symptoms. subsequently results in steatotic liver condition [22]. In the cur-
In order to show association between clinico-demo- rent study, we found a significantly higher value of AST in Child’s B
graphic and laboratory profile with the severity of hepatic cir- group than child’s A group (p=0.398); and similarly, the AST/ALT
rhosis, CTP-A was compared with CTP-B. In this study, there ratio was more than 1 or higher in cirrhotic Child’s B than Child’s
was a significant association between the severity of hepatic cir- A (p=0.001). These figures were in line with other studies [23]. It
rhosis and the older age (p=0.0068), lower weight (p=0.0196), is well known that as chronic liver disease is getting worse, the
low hemoglobin (p=0.0249), low WBC (p=0.027), low platelet AST/ALT ratio is in increasing. Although the exact reason is not
(p=0.0001), high prothrombin time (p=0.0001), increased TSB clear for this finding; however, it has been suggested that clear-
(p=0.0001), decreased serum albumin (p=0.0003), decreased ance of AST by sinusoidal cells of the liver is decreasing as liver
triglyceride (p=0.0476), increased AST (p=0.0398), AST/ALT cirrhosis progresses [24]. Furthermore, we found that ALP level
ratio (≥1) (p≥0.001), and increased ALP (p=0079). However, a was significantly higher among Child’s B than Child’s A group. In
significant statistical association was not found between the se- contrast to my finding, Das et al. [25] reported that ALP level re-
verity of hepatic cirrhosis and sex (p=0.687), ethnicity (p=0.613), mains normal in cirrhotic patients. Recent reports documented
FBS (p=0.4248), serum protein (p=0.2015), ALT (p=0.8716), that the hypoalbuminemia and elevated ALP level in chronic liver
AFP (p=0.6235), HBeAg positivity (p=0.298), anti-HBe positive disease is associated with poor overall survival. Therefore, the
(p=0.453), and viral load (p=0.3559). Similar to the findings in high risk albumin to alkaline phosphatase ratio (AAPR) is associ-
the present study, van der Plas et al. [15] reported more frequent ated with poor prognostic feature, which includes CTP-B and C
liver cirrhosis among older age and men gender. Although, there score [26]. In this study, 2 patients died from HCC in CTP-C. It is
were more severe hepatic cirrhotic men patients in this study, the well known that HCC is the first cause of death among cirrhotic
association was not significant (p=0.687). In the current study, patients [27].
patients with Child–Pugh score B were significantly associated Although the duration of my study was 27 months, the
with lower body weight (p=0.0196), which was consistent with sample size was small. Furthermore, I did not include some im-
the finding of Li et al. [16]. Generally, in this study, patients with portant parameters such as HDV co-infection, and GGT level, be-
higher BMI were linked with higher albumin level and better cause these investigations were not available regularly through-
liver enzymes, which results mild hepatic cirrhosis (Child’s A). out the study periods.
Furthermore, it is well known that the muscle mass is decreasing In conclusion, the current study investigated the asso-
as liver cirrhosis progresses. In over all, the patients were over- ciations between variables among CTP categories of chronic HBV
weight in this study, which was consistent with the finding of BMI patients related to liver cirrhosis in Duhok province. The cirrhotic
of other literatures [17]. In contrast, Li et al. reported that the patients with CTP-B were older, lower weighted, lower hemoglo-
majority of the patients in their study were either underweight or bin level, lower WBC count, lower platelet counts, increased pro-

Citation: Muayad A Merza (2017) Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Care Refer- Page 4 of 5
ral Hospital, Duhok, Iraqi Kurdistan. Gastroenterol Pancreatol Liver Disord. 4(5): 1-5.
DOI: http://dx.doi. org/10.15226/2374-815X/4/5/00199
Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Copyright:
Care Referral Hospital, Duhok, Iraqi Kurdistan © 2017 Muayad A Merza

thrombin time, increased TSB level, decreased serum albumin 12. Stroffolini T, Esvan R, Biliotti E, Sagnelli E, Gaeta GB, Almasio PL. Gen-
level, decreased triglyceride level, increased AST level, AST/ALT der differences in chronic HBsAg carriers in Italy: evidence for the
ratio (≥1), and increased ALP level. Although no significant as- independent role of male sex in severity of liver disease. J Med Virol.
sociation was found between HBV related to cirrhosis and other 2015;87(11):1899–1903. doi:10.1002/jmv.24243
variables such as viral load, a larger cohort study with extended 13. Merza MA, Haji SM, Alsharafani AM, Muhammed SU. Low prevalence
parameters are warranted to ascertain the association with se- of hepatitis B and C among tuberculosis patients in Duhok Province,
verity of the hepatic cirrhosis. Kurdistan: Are HBsAg and anti-HCV prerequisite screening parameters
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Acknowledgements
14. Stroffolini T, Sagnelli E, Gaeta GB, Sagnelli C, Andriulli A, Brancaccio
We would like to thank all staff of the viral hepa-
G, et al. Characteristics of liver cirrhosis in Italy: Evidence for a de-
titis clinic in Azadi Teaching Hospital, Duhok province
creasing role of HCV aetiology. Eur J Intern Med. 2017;38:68-72. doi:
for their kind help and support in performing this study. 10.1016/j.ejim.2016.10.012
15. van der Plas SM, Hansen BE, de Boer JB, Stijnen T, Passchier J, de Man
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Citation: Muayad A Merza (2017) Characteristics of Chronic Hepatitis B Virus Patients Related Liver Cirrhosis in a Tertiary Care Refer- Page 5 of 5
ral Hospital, Duhok, Iraqi Kurdistan. Gastroenterol Pancreatol Liver Disord. 4(5): 1-5.
DOI: http://dx.doi. org/10.15226/2374-815X/4/5/00199

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