Ambulatory end-stage liver disease in Ghana; patient profile and utility of alpha fetoprotein and aspartate aminotransferase - platelet ratio index

Abstract

Background: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST) - platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana. Methods: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and Alpha fetoprotein in the diagnosis of HCC was determined using AUROC analysis.Results: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation. Conclusions: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.

Mortality burden due to liver cirrhosis and hepatocellular carcinoma in Ghana; prevalence of risk factors and predictors of poor in-hospital survival

“…Another reason is the possibility that patients had insufficient test results for practitioners to arrive at a more specific diagnosis, as is common-place in low-resource settings. This may be related to the high cost of care associated with these conditions, which is often a barrier to definitive diagnosis and treatment [ 15 , 21 , 22 ].…”

“…The relatively lower burden of HBV-related ESLD in regions such as parts of Europe and North America are related to effective and stringent measures including injection blood safety, infection control strategies, antenatal screening and widespread acceptability of childhood vaccination [ 25 ]. Previous studies in Ghana have reported the high proportion of liver cancer and liver cirrhosis cases attributable to HBV infection [ 4 , 15 , 16 ], and this emphasizes the need for improved policies and strategies to reduce the HBV burden in Ghana. Although there is a national policy on viral hepatitis [ 26 , 27 ], the country has been unable to meet diagnosis and treatment targets for HBV and HCV infection, is yet to attain elimination goals, and has no published financing plan to achieve these aims.…”

“…An assessment of predictors of mortality in higher level centres in Ghana which are better equipped and often serve as the final point of referral for end-stage liver disease (ESLD) cases is warranted to better understand mortality patterns associated with ESLD. Furthermore, there is a paucity of studies on predictors of mortality in HCC patients in Ghana, although the literature shows that patients often present at advanced stages of the disease [ 15 , 16 ]. An improved understanding is important to help inform clinical decision making, direct policy and develop preventive strategies for improved survival.…”

Clinical Profile and Limitations in the Management of HBV Patients Attending Clinic at a District Hospital in Ghana

“…The sample size was determined using Cochran's formula for sample size calculation. With an estimated prevalence of 12.5% for HBV in Ghana (12), a Z -score at 95% confidence level (1.96), and a level of significance of 0.05, the minimum sample size was calculated to be 166. Due to the high attrition rate for prospective studies, 334 participants were consecutively recruited after meeting the study criteria and giving informed consent.…”

“…The most critical problem in the management of CHB in Africa including Ghana is the high cost of laboratory tests and drugs. One of the barriers identified in this country to HBV treatment is the high cost; however, this was based on qualitative studies [11,12]. Anecdotal evidence suggests that drugs for treatment may not be widely available, especially in district hospitals in Ghana and even if available may be too expensive for patients to buy.…”