chronic viral hepatitis b ( cvhb ) remains a common health problem throughout the world . in recent years , due to increased information about the transmission of hepatitis b virus ( hbv ) and the application of precautions , such as routine hbv vaccination programs , hbv prevalence has been declining ( 1 , 2 ) . however , with increasing life expectancy , the use of antiviral medications is prolonged and therefore drug resistance is increasing . liver biopsy is still necessary for predicting underlying hbv - related liver injury and for deciding whether to initiate antiviral medication ( 3 ) . liver biopsy is an invasive procedure with certain risks , which forces investigators to focus on non - invasive methods to replace percutaneous biopsy ( 4 ) . assessing liver stiffness with ultrasound and measuring serum biomarkers are inadequate for determining the severity of liver fibrosis or for grading the inflammatory process in the liver . the programmed cell death of apoptosis is a protective mechanism in infected hepatocytes , not only to prevent spread of the virus to other hepatocytes and to control viral replication ( 5 ) , but also to decrease pro - inflammatory cytokine release from injured hepatocytes ( 6 ) . upregulation of apoptosis has been shown to have a critical role in inducing inflammation and fibrogenesis in the liver . the amount of cytokeratin-18 fragments cleaved by caspases during apoptosis seems to be a good marker of apoptosis ( 7 ) , and can easily be measured with a sandwich elisa technique ( m30-based elisa ) ( 8) . serum m30 levels were higher in chronic hbv patients compared to healthy controls , and m30 levels were able to be used to discriminate mild from advanced liver fibrosis ( 9 , 10 ) . in addition , giannousis et al . showed a decrease in serum m30 levels after six months of antiviral therapy ( 11 ) . the aim of this study was to investigate the utility of serum m30 levels in predicting the hepatic fibrosis stage in cvhb patients . forty patients admitted to our clinic between january and december 2011 , who underwent liver biopsy with a diagnosis of chb , were included in this cross - sectional study . the exclusion criteria were co - infection with hepatitis c virus or human immunodeficiency virus ( hiv ) , alcohol abuse ( 40 g / day for men and 20 g / day for women ) , biopsy - proven non - alcoholic steatohepatitis , or any immunological liver disease . the decision to perform liver biopsy was based on the easl hbv guidelines ( 3 ) . approval for the study was granted by the local clinical research ethics committee , and informed consent was obtained from each patient . the baseline characteristics of the patients and their laboratory results , including alanine aminotransferase ( alt ) , aspartate aminotransferase ( ast ) , platelet count , and hbv dna , were collected from the computerized hospital database . blood samples were obtained from the patients after informed consent on the same day as the liver biopsy , and were stored at -80c until the procedure was completed . m30 values were measured using an m30 elisa kit ( peviva ; bromma , sweden ) according to the manufacturer s recommendations . the severity of fibrosis was assessed as mild ( f0 and f1 ) , moderate ( f2 and f3 ) , or advanced ( f4 and f5 ) , and the histological activity index ( hai ) was classified as mild ( 1 - 5 ) , moderate ( 6 - 8) , or severe ( 9 - 12 ) . forty healthy controls were also included in the study for comparison with the patient group s laboratory parameters , including m30 , alt , ast , and platelet count . all of the controls completed a questionnaire to determine whether they had any chronic illness that could affect the results , and digital data from our hospital were used to evaluate the presence of chronic hepatitis and possible etiologic factors , such as viral hepatitis or hiv . the statistical package for the social sciences ( spss software version 17.0 , spss inc . , baseline demographic values were calculated with the kruskal - wallis test , then the post - hoc test was performed . the continuous variables were summarized as mean  standard deviation ( sd ) , or minimum ( min ) and maximum ( max ) for certain categorized values . twenty - five ( 52% ) of the cvhb patients were male , and their mean age was 45.7 years , which were both higher than in the controls ( table 1 ) . five of these patients ( 10% ) were hbeag - positive and the remainder were negative . baseline laboratory evaluations revealed that the cvhb patients had higher alt , ast , and m30 levels and lower platelet counts compared to the controls . mean age , duration of disease , and platelet count did not differ according to the severity of liver fibrosis ( table 2 ) . m30 levels were also similar in each group . however , ast and alt levels were prominently increased in the moderate group compared to the mild fibrosis group . in contrast , hbv dna levels decreased as the severity of fibrosis increased ( p = 0.007 ) . . transaminase level , hbv dna level , platelet count , mean age , and duration of disease were all similar among the groups ( table 3 ) . abbreviations : hai , histological activity index ; alt , alanine aminotransferase ; ast , aspartate aminotransferase . the correlation analysis revealed a weak correlation between m30 and hbv dna levels ( r = 0.354 , p = 0.013 ) , but no correlation was observed among alt and ast values ( r = 0.270 , p = 061 and r = 0.244 , p = 0.92 ; respectively ) . the main target of antiviral medication therapy against hbv is the prevention of hbv - related morbidities , which are mainly liver insufficiency and hepatocellular carcinoma ( 3 ) . since recent studies have shown a correlation between hbv dna and hbv - associated disorders , monitoring the hbv dna load has become a crucial part of hbv therapy . however , apart from monitoring the hbv dna viral load and transaminase levels , there are no other serological markers for predicting the severity of ongoing inflammatory or fibrotic processes . however , some studies of non - invasive markers for predicting the severity of liver fibrosis are available in the medical literature ( 12 - 15 ) . unfortunately , none of these parameters reflect the real status of the liver , which is only possible with liver biopsy . apoptosis , programmed cell death , is crucial when it becomes dysregulated in chronic hepatitis , such as in viral hepatitis , alcoholic and non - alcoholic steatohepatitis , cholestatic processes , and wilson s disease ( 16 - 19 ) . the increase of apoptotic cells results in cytokine secretion , leading to induction of inflammatory and fibrotic processes ( figure 1 ) ( 6 ) . downstream from the cell - death receptor , the proteolytic cascade leads to activation of caspases 3 , 6 , and 7 ( 16 , 20 ) . the activation of caspases may be related to mitochondrial dysfunction , leading to cytochrome c release or direct cleavage ( 20 , 21 ) . the susceptibility to apoptotic cell death may depend on the hbv genotype , as well ( 22 ) . not only apoptotic cell death , but also autophagic cell death , may be good predictors for defining the level of liver injury at the beginning of treatment and during the follow - up period ( 23 ) . similar to our results , m30 levels in the healthy population were found to be lower than in chb patients ( 6 , 10 , 18 , 23 ) . as expected , eren et al . higher m30 values in chb patients compared to healthy individuals is understandable , due to ongoing liver inflammation . serum m30 levels were found to be significantly higher in chronic hbv patients compared to healthy subjects ( 10 , 18 , 23 ) . moreover , one study found that m30 values increased with increasing severity of liver fibrosis , and reached their highest level in cirrhotic patients ( 23 ) . however , the role of apoptotic markers for replacing liver biopsy in chb patients and the utility of m30 levels for distinguishing inactive chb carriers from chb patients are still controversial . papatheodoridis et al . gave a cut - off value of 240 u / l for predicting chb with 60% sensitivity and 100% specificity ( 9 ) . . determined a cut - off value of 157.5 u / l for predicting mild fibrosis from significant fibrosis (  f2 ) in the liver ( 64% sensitivity and 61% specificity ) ( 18 ) . differentiating ongoing high - inflammation processes and high fibrosis scores in the liver is crucial for the initiation of antiviral medication without requiring liver biopsy . , we were unable to identify any relationship between m30 values and the mild to moderate stages of liver fibrosis ( 10 , 18 ) . therefore , we could not find a sufficient number hbv patients with advanced liver fibrosis . the alt - to - platelet ratio ( the apri index ) and the fib-4 scores , which are based on alt , ast , platelet count , and age of the patient , have been widely investigated . although there were some promising results , large - scale database studies revealed that the apri index and fib-4 scores may not be adequate for predicting the severity of underlying liver disease in hbv patients ( 24 , 25 ) . our results support the idea that the apri index and fib-4 scores are not correlated with the severity of liver fibrosis ( unpublished data ) . in conclusion , although m30 levels were higher in cvhb patients than in healthy controls , our results do not support the use of m30 levels for predicting the severity of underlying fibrotic or inflammatory processes in chb patients . further studies are necessary in order to clarify the role of apoptotic mechanisms in hepatic injury due to hbv , and to establish the utility of m30 in replacing liver biopsy .
backgroundliver biopsy is an invasive procedure that is currently still necessary for predicting underlying hepatic injury related to chronic viral hepatitis b ( cvhb ) . to date , none of the studied non - invasive methods have been able to replace liver biopsy . an apoptotic serum marker , m30 , which has been reported to indicate ongoing liver fibrosis , has been popular in recent years.objectiveswe aimed to investigate the possible role of m30 in predicting cvhb - associated hepatic injury and its severity.methodsforty-eight patients undergoing liver biopsy for evaluation of the severity of cvhb - related liver injury and 40 healthy controls were included in this cross - sectional study . 
 m30 levels were determined for all cvhb patients and controls , and other laboratory parameters and demographic features were obtained from our hospital s database.resultsthe mean ages of patients and controls were 39.7 and 45.7 years , respectively , and 35% of the controls and 52% of the patients were male . 
 in contrast to lower platelet counts , transaminase and m30 levels were both higher in the patient group than in the controls . among the investigated parameters , only transaminase increased as the fibrosis stage changed from mild to moderate ; however , none of the laboratory parameters , including m30 , differed as the histological activity index ( hai ) score increased.conclusionsm30 levels were higher in cvhb patients compared to healthy controls . 
 however , m30 levels were similar in the mild and moderate stages of fibrosis , so they did not indicate the severity of underlying fibrotic or inflammatory processes in cvhb patients .