CV

dr. Rudianto, SpPK

• BIRTH : September ,1972
• 2001 : Medical Doctor, University of Methodist Indonesia, Medan
• 2010 : Clinical Pathologist, University of Indonesia, Jakarta

• WORK EXPERIENCE:
• Medical doctor, 2002-2005
• Staff temporary for Cipto Mangunkusumo Hospital, Jakarta, 2009-2010
• Head of Clinical Laboratory at RS Anna Medika , Bekasi, 2010-now
• Scientific Manager PT Sysmex Indonesia, Jakarta, 2011-now

• ORGANIZATION :
• Member of Ikatan Dokter Indonesia (IDI) Jakarta Timur-Since 2010
• Member of PDS Patklin cabang Jakarta- Since 2010
• Member of ISLH – Since 2012
Liver Fibrosis
 Introduction

• Part of the structural and functional

alterations in most chronic liver diseases

• Main prognostic factors as the amount of

fibrosis is correlated with the risk of
developing cirrhosis and liver-related
complications in viral and nonviral chronic
liver diseases

Biomarker Insights 2012:7

• Liver biopsy has traditionally been
considered the reference method for
evaluation of tissue damage such as
hepatic fibrosis in patients with chronic
liver disease

• METAVIR score  robust scoring system

for staging liver fibrosis
 Demerits of Liver Biopsy

• Provides only a very small part of the

whole organ and there is a risk that this
part might not be representative
• Costly
• Invasive
• Well trained staff

NON INVASIVE
TECHNIQUE
 Non Invasive Technique

• Rely on two different approaches

1. A ‘‘biological’’ approach based on the
quantification of biomarkers in serum
samples
2. A ‘‘physical’’ approach based on the
measurement of liver stiffness (LS)
 A ‘‘biological’’ approach

• Using serum biomarkers indicate several,

not strictly liver specific clinical and serum
parameters that have been associated
with fibrosis stage, as assessed by liver
biopsy
 Classification of Serum marker

Class I fibrosis markers :

• Direct serum markers,which molecules derived from -
ECM turnover reflecting activity fibrotic process, and
indicate the extent of connective tissue deposition
Class II fibrosis biomarkers :
• Indirect serum fibrosis biomarkers that have been used
in clinical practice and have been identified from
retrospective studies
• Calculated by mathematical algorithms, and do not
necessarily reflect ECM turnover and/or fibrogenic cell
changes

Biomarker Insights 2012:7

Mechanisms of hepatic fibrogenesis and
possible molecular serum biomarkers.

Biomarker Insights 2012:7

Serum Biomarker Tests

Journal of Hepatology 2015 vol. 63: 237–64

 A ‘‘physical’’ approach

• Corresponds to a genuine and intrinsic

physical property of liver parenchyma

• Examples : Transient elastography, liver

elasticity-based imaging techniques
Advantages

Journal of Hepatology 2015 vol. 63: 237–64

Disanvantages

Journal of Hepatology 2015 vol. 63: 237–64

Performance of serum biomarkers for
staging liver fibrosis

Journal of Hepatology 2015 vol. 63: 237–64

 New Biomarker Serum
M2BP : Mac2 Binding Protein
Glycoprotein biomarker for liver fibrosis

Altered quality & quantity of M2BP due to changes in N-

glycosylation seen in liver disease
 M2BPGi : Mac2 Binding Protein Glycosylation isomer

HISCL M2BPGi Assay

→ measures the altered glycosylation isomer due to the presence of liver fibrosis

M2BP protein (NOT M2BPGi)

concentration also correlates with the
staging of liver fibrosis.
M2BP level (ug/ml)

Cheung et al. (2009)

Measurement of M2BPGi having the

altered glycan chains
→ improvement of correlation with the
staging of liver fibrosis
Hepatic fibrosis score
 New Serum Biomarker
• Release in January 1st, 2015
• The Wisteria floribunda agglutinin-positive
human Mac-2 binding protein (WFA+-M2BP) is a
novel marker for the assessment of liver fibrosis
• A number of clinical studies showed that WFA+-
M2BP reflects the progression of liver fibrosis.
• Furthermore, a study targeting patients with
hepatitis C suggested that WFA+-M2BP is useful
in predicting for the development of
hepatocellular carcinoma.

Yuichiro Ide1) 、Yoko Usami1) 、Nau Ishimine1) 、Kazuhiro Nagata1) 、Kenji Kawasaki1) 、Mitsutoshi
Sugano1) 、Takayuki Honda1) Department of Laboratory Medicine, Shinshu University Hospita
 Glycoprotein
glycan: oligomer of monosaccharide
(such as glucose)
Glycan※
Glycoprotein

Protein
Central dogma

※
Protein

Nucleus
Glycoprotein:
oligosaccharide chains covalently
attached to polypeptide side-chains

The structure of glycan reflects the condition of the living body, therefore, this
has a great clinical significance in terms of diagnosis.
 M2BP to M2BPGi

Glycoprotein in serum

Glycoprotein AFP
from M2BP
normal cells
Different
glycan
Glycoprotein structure
from
Secretion
abnormal cells
AFP-L3
Secretion
M2BPGi
Normal
cell
Abnormal cell
The glycan structure is altered depending on the condition of the cell.
 Mac-2 binding protein (M2BP)

Glycoprotein biomarker for liver fibrosis

“Sugar-powdered doughnut” large ring structure by
oligomerization
Altered quality & quantity of M2BP due to changes in N-
glycosylation is seen in liver disease

SCIENTIFIC REPORTS | 3 : 1065 | DOI: 10.1038/srep01065

Rapid diagnosis of the liver fibrosis staging
from chronic hepatitis to cirrhosis
Specific detection
of the deformed
glycan structure
F1 F2 F3 F4 using lectin
Deformed glycan
structure in the
The glycan structure presence of liver
of a healthy person disease

Glycan

Liver fibrosis progression

Schematic illustration of the change in glycan structure by

progression of liver fibrosis
 WFA+-M2BP

• Glycans are referred to as the face of cells, which reflect

their status such as differentiation stage rather than their
state of damage
• Therefore can be great markers for chronic disease.
• In the case of hepatitis, glycans are considered to reflect
more specifically the progression of fibrosis than viral
load.
• That is not markedly affected by tissue inflammation and
ALT fluctuation, the possibility of glycomic and
glycoproteomic techniques has emerged

SCIENTIFIC REPORTS | 3 : 1065 | DOI: 10.1038/srep01065

Using a glycosylation marker as a liver fibrosis marker
(HISCL M2BPGi)
F1 F2 F3 F4

Progression of Liver fibrosis

Quantitative protein Measurement of glycosylation

changes : HA structure (glycosylation
Collagen PIIIP isomer)
 Assay flow

Detection of chemiluminescence High

Lectin-based sandwich assay
sensitivity

M2 ALP
M2 BP
ALP-labeled ALP ALP
BP M2
BP antibody
M2
M2 BP M2
BP BP

MP
Serum Lectin
（10 mL） MP High High
10min 7min
speed specificity

17 min HISCL-5000

SCIENTIFIC REPORTS | 3 : 1065 | DOI: 10.1038/srep01065

Principle of M2BPGi measurement

Antigen-Antibody Complex Glycan-Lectin Reaction

（conventional technology） （new technology）
Monoclonal antibody M2BP
which is labeled with ALP

ALP
ALP

ALP ALP Glycosylated

Antigen protein M2BP
M2BP

Ag Ag
Lectin

MP MP
MP
Biotin
Antibody

Streptavidin

SCIENTIFIC REPORTS | 3 : 1065 | DOI: 10.1038/srep01065

 Clinical evaluation results
WFA+-M2BP M2BPGi＊
Detect M2BPGi by WFA Lectin (P<0.0001)

107

Chemiluminescent intensity
Anti-M2BP
Antibody 106
M2BP
(Do not Bind
with WFA:WFA-)
M2BPGi 105
(Bind with WFA：WFA+)

× 104

HV1 HV2 F01 F2 F3 F4

(47) (70) (82) (52) (40) (35)
WFA Lectin
Kuno A et al., Sci Rep (2013)
Correlation with liver fibrosis stages

HV - Healthy volunteers
CHC - Chronic hepatitis C Patients
CL - Cirrhosis of the Liver

HV F0F1 F2 F3 F4
（N=117) （N=81) （N=52) （N=40) （N=31)

Kuno A et al., Scientific reports, 3, 1065 (2013)

Correlation between liver fibrosis stages & COI

Chronic
Cirrhosis
Normal hepatitis (F0
(F4)
– F3)

Toshima T, et al. J Gastroenterol. 2014 DOI 10.1007/s00535-014-

0946-y
 Fibrosis Score

The fibrosis score is also assigned a number from 0-4:

• F0 = no scarring/ no Fibrosis
• F1 = minimal scarring/enlarged, fibrotic portal tract
• F2 = scarring has occurred and extends outside the
areas in the liver that contains blood vessels/periportal
septa with intact architecture
• F3=bridging fibrosis is spreading and connecting to other
areas that contain fibrosis/Fibrosis with distortion
architecture but no chirrhosis
• F4=cirrhosis or advanced scarring of the liver

HCSP • VERSION 2.2 • October 2007

 HISCL M2BPGi assay

Rapid and simple glycan-based immunoassay

Can quantify fibrosis precisely

Readily evaluate the anti-fibrotic effects of therapy

Not affected by tissue inflammation and ALT fluctuation

ROC analysis shows M2BPGi as sensitive and
specific marker
Correlation between liver fibrosis stages & COI

Chronic
Cirrhosis
Normal hepatitis (F0
(F4)
– F3)

J Gastroenterol .DOI 10.1007/s00535-014-0946-y

Comparison of WFA -M2BP with other indicators
for the diagnosis of fibrosis stage F C 3

J Gastroenterol .DOI 10.1007/s00535-014-0946-y

Toshima T, et al. J Gastroenterol. 2014 DOI 10.1007/s00535-014-
0946-y
 Specification of HISCL M2BPGi

Measurement Range：C.O.I.＝0.10～20.00（Semi-quantitative method）

Determination Methods：

Negative（C.O.I. ＜ 1.0） C.O.I for non-chronic hepatitis

Positive 1+（1.0 ≦ C.O.I. ＜ 3.0）C.O.I for chronic hepatitis
Positive 2+（C.O.I. ≧ 3.0） C.O.I for cirrhosis
Comparison among M2BPGi and existing methods
Blood test(HISCL)
Comparison performance
肝硬変診断のROC 解析（対照法：肝生検among blood tests
n=115 件）
by ROC analysis
Correlation between liver fibrosis stage and C.O.I 100%
1.0
80%
0.8

Sensitivity
Performance Hepatic肝硬変の判定
cirrhosis judgment

Sensitivity
60%
high 0.6 AUC
HISCL 法 0.942
40%
ﾋｱﾙﾛﾝ酸
HA 0.896
0.4
Liver biopsy 20%
(FIB4)
FIB4 0.882
血小板
PLT 0.865
○ Gold standard 0.2
× Invasive 0% F0～F4 n=115
× Multistep process in diagnosis 0%
0.0 20% 40% 60% 80% 100%
1.0 0.8 Specificity
0.6 0.4 0.2 0.0
△ Hard to grasp clinical condition Specificity
of whole liver Hepatic M2BPGi is the most sensitive & specific in other blood tests
Nor Chronic hepatitis
△ Require expertise cirrhosis
mal （F0-F3)
(F4)
○ Non-invasive, utilize blood for liver function test
M2BPGi reflects fibrosis stage
○ High specificity
○ Monitoring of therapeutic gains
Liver biopsy HISCL
Invasive Non-invasive

FibroScan (Transient elastography)

○ Non invasive, quantify degree of
Elastography imaging hardness using ultrasound wave
× Strongly affected by inflammation
× Faint image for fat deposit and fatty liver
△ Require special skill

Performance Blood test(Hyaluronic acid, Type Ⅳcollagen）

low ○ Non invasive, utilize blood for liver function test
Existing markers × Low specificity, results are easily affected by pre-analytics
△ Hard to judge liver fibrosis progression and therapeutic
gain by blood kinetics' change being small

M2BPGi has high performance & is non-invasive.

Proposed algorithm for the use of non-invasive tests in
treatment naive patients with Hepatitis C
with or without HIV coinfection.

Journal of Hepatology 2015 vol. 63j: 237–64

 To conclude..

 NAFLD & NASH are growing medical threat.

 Liver biopsy is still the gold standard.
 M2BPGi is direct precise marker for liver
fibrosis.
 Uses routine blood serum samples.
 Can be used for liver fibrosis assessment in
mixed, chronic hepatitis and NAFLD patient
groups.
 HISCL M2BPGi assay

Rapid and simple glycan-based immunoassay

Can quantify fibrosis with different causes such as

HCV, HBV, NASH and other etiologies.

Readily evaluate the anti-fibrotic effects of therapy

Not affected by tissue inflammation and ALT

fluctuation

Can predict the development of HCC (in HCV).