Research on FibroTouch Noninvasive Evaluation of Liver Fibrosis and Cirrhosis
Conditions: Liver Fibrosis, Cirrhosis, Chronic Hepatitis B
Sponsor: Wuxi Hisky Medical Technology Co Ltd

CHINESE CLINICAL TRIAL PROTOCOL
FibroTouch Non-invasive Evaluation of Liver Fibrosis and Cirrhosis
Principal Center:
01
Beijing Friendship Hospital, Capital Medical University
Other Participant Center:
02
The Military General Hospital of Beijing, PLA
03
The First Affiliated Hospital, Third Military University
04
The First Affiliated Hospital, Fourth Military University
05
The First Bethune Hospital, Jilin University
06
The Third Hospital, Hebei Medical University
07
Henan Provincial People Hospital
08
Jiangsu Provincial People Hospital
09
Ruijin Hospital, Shanghai Jiaotong University School of Medicine
10
West China Hospital, Sichuan University
11
Tianjin Third Central Hospital
12
Prince of Wales Hospital, Chinese University of Hong Kong
13
No.85 Hospital of the PLA
14
The Third Hospital, Sun Yat-sen University
15
Beijing Youan Hospital, Capital Medical University
16
Xinjiang Uygur Autonomous Region Hospital of Traditional Chinese
Medicine Hospital
17
China-Japan Friendship Hospital
Sponsor: Wuxi Hisky Medical Technology Co., Ltd.
April 17, 2014
Protocol version: 1.1

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This protocol is unanimously passed after the discussion among investigators from the
principal center and other participant centers, sponsor and the principal statistician
from statistical group.
1. Sponsor
I will, according to the relevant regulations (e.g. Chinese Good Clinical Practice, and
Regulations for the Clinical Study on Medical Device), carefully perform the duties of the
sponsor to initiate, apply, organize and aid this study, afford the relevant medical expenses,
legal liability and proper economic compensation for the incurred damage related to the study
device during this study, and offer the legal guarantee for the investigators. I also agree to
carry out this study strictly according to the design and specifications of this protocol.
Sponsor: Wuxi Hisky Medical Technology Co., Ltd.
Legal representative (signature):
Shao Jinhua
Date:
2. Principal investigator
I will, according to the relevant regulations (e.g. Chinese Good Clinical Practice,
Regulations for the Clinical Study on Medical Device and Declaration of Helsinki), carefully
perform the duties of the principal investigator. I agree to carry out this study strictly
according to the design and specifications of this protocol. Before the starting, during the
progress and at the end of this study, I will carefully coordinate in time each participant on the
relevant matters in this study, so as to guarantee the smooth progress of this study at this
clinical trial phase.
Responsible institution: Beijing Friendship Hospital, Capital Medical University
Principal investigator (signature):
Jia Jidong
Date:
3. Statisticians:
Peking University Clinical Research Institute
Principal statistician (signature):
Yao Chen
Date:

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Abbreviation
Abbreviation
Term
AE
Adverse event
CRF
Case Report Form
EC
Ethic Committee
ECG
Electrocardiography
FAS
Full analytical set
GCP
Good Clinical Practice
PPS
Per-protocol set
SAE
Serious adverse event
SAP
Statistical analytical plan
SD
Source data
CFDA
China Food and Drug Administration
SS
Safety set
PTA
Prothrombin activity
TP
Total protein
ALB
Albumin
AST
Aspartic transaminase
ALT
Alanine transaminase
ALP
Alkaline phosphatase
GGT
Glutamyl transpeptidase
TBIL
Total bilirubin
DBIL
Direct bilirubin
TC
Total cholesterol
TG
Triglyceride
HDL
Blood lipid – high-density lipoprotein
LDL
Blood lipid – low-density lipoprotein
AFP
Serum alpha-fetoprotein
GHb
Glycosylated hemoglobin
FPG
Fasting plasma glucose
INS
Serum insulin

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Table of Contents
Abbreviation ······························································································· 3
I. Study Background······················································································ 5
II. Study Objective ························································································ 6
III. Study Goal ····························································································· 7
IV. Study Type ····························································································· 7
V. Anticipated Total Cases··············································································· 7
VI. Study Time ···························································································· 8
VII. Case Assignment (via the central registration system) ·········································8
VIII. Statistical Processing ···············································································8
IX. Study Design ·························································································· 8
(I) Inclusion criteria ··················································································8
(II) Exclusion criteria ················································································8
(III) Study method ··················································································· 9
(IV) Safety evaluation ············································································· 13
(V) Quality control and quality assurance of clinical study ··································15
(VI) Study-related ethical requirements and ICF ·············································· 16
(VII) Statistical analysis of data ··································································16
(VIII) Data management and data traceability ················································· 17
X. Anticipated Schedule of Clinical Study ···························································19
Appendix 1: Quality Control of Central Laboratory ················································20
Appendix 2: Flow Chart of Study Design ····························································23
Appendix 3: Knodell System: scoring system of liver histological activity index (HAI) ·····24
Appendix 4: Evaluation Protocol for the Staging and Scoring of Liver Fibrosis ·············· 25

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I. Study Background
The liver diseases frequently occur in China. For various reasons, the chronic liver
diseases are not controlled in time, and then develop gradually into liver fibrosis and cirrhosis.
Without effective treatment, the advanced liver cirrhosis seriously influences the quality of
life of patients, and places an intolerable burden on family and society. At present, the scholar
generally thought that the liver fibrosis at early stage is reversible. Therefore, if the liver
fibrosis in patients with chronic liver diseases can be accurately evaluated at early stage and
be treated in time, so we can stop the progress of diseases and reduce the occurrence of liver
cirrhosis and liver cancer.
For many years, liver biopsy is still as “golden standard” for diagnosis of liver
inflammation and fibrosis. However, with its invasiveness, potential risks and some
complications, liver biopsy is limited in clinical application due to the poor acceptability and
repeatability. In recent years, the liver fibrosis cannot directly and accurately diagnose via the
various diagnostic model using serological biomarkers (e.g. FIBROTEST and FIBROSIS
PREDICTIVE APRI) and medical imaging technology (e.g. ultrasonic B, CT and MRI).
Transient elastography is a new technology in the field of ultrasonic imaging. Liver
stiffness measurement (LSM) is based on the relationship between speed of the spread of
acoustic wave and stiffness of tissues. It utilizes specific probes to send out controlled
low-frequency shear waves, the waves signals transmit through liver tissues, a high-frequency
signals to track the transmitting process of shear wave in the liver and the value of liver
stiffness (KPa) is quickly calculated with reference to a built-in liver histological model,
which provides a quantitative standard for diagnosis of liver fibrosis of chronic liver disease.
The bigger LSM value means the faster transmission of shear wave, and the harder of
determined tissue.
At present, FibroScan (France, Echosens) as a transient elastography product, has been
widely applied in clinical practice. Many studies both at home and abroad on chronic hepatitis
B (CHB) and chronic hepatitis C have demonstrated that transient elastography is well
correlated to liver histology by liver biopsy in diagnosis of liver fibrosis and cirrhosis.
Recently, FibroScan is well recognized at various meetings and recommended by many

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medical guidelines.
Marianne et al studied on 327 patients with chronic hepatitis C, each patient was scoring
by METAVIR system, and the median value of LSM for F0-1, F2, F3 and F4 was 5.5 (4.1-7.1)
kPa, 6.6 (4.8-9.6) kPa, 10.3 (7.6-12.9) kPa and 30.8 (16.3-48) kPa respectively; and the Area
Under ROC (AUR) for F≥2, F≥3 and F=4 (METAVIR scoring system) was 0.79, 0.91 and
0.97 respectively. Therefore, the LSM varied significantly (P<0.0001) and was significantly
related to the liver fibrosis (tau beta of Kendall, 0.55; P<0.0001).
A multi-center and large-sample comparison study between FibroScan and liver biopsy
in the chronic hepatitis B patients in China also demonstrated that LSM had good diagnostic
accordance rate to the pathological stages. The cut-off value of pathological stages≥F4 was
17.5 kPa as, the sensitivity and specificity were 0.6 and 0.93 respectively; the cut-off value of
pathological stages ≥F3 was 12.4kPa, the sensitivity and specificity were 0.58 and 0.95
respectively; the cut-off value of pathological stages=F2-F3 was 12.4kPa, the sensitivity and
specificity were 0.73 and 0.90 respectively; and the cut-off value of pathological stages≥F2
was 7.3kPa, the sensitivity and specificity were 0.66 and 0.83 respectively.
As stated in the “12th Five-year Plan for Medical Device Technological Industry” (the
Ministry of Science and Technology), China will greatly support the research and
development of new medical devices and promote the application of Chinese transient
elastography system, FibroTouch, which was R&D by Tsing-Hua University independently
with new algorithm. FibroTouch can rapidly determine the LSM in a non-invasive way and
provide useful information for liver fibrosis staging.
As reported by a recent study on 214 CHB patients in Beijing Friendship Hospital
underwent FibroScan testing and FibroTouch testing at the same time.
FibroTouch and
FibmScan have good consistency in the evaluation of the degree of liver fibrosis．FibroTouch
has a significantly higher rate of effective detection (99% vs. 72%) and higher rate of
successful detection than FibroScan (100% vs. 97%).
Due to FibroTouch is a new transient elastography system in marketing, there is no too
much study on the correlation between FibroTouch and liver biopsy in diagnosis of liver
fibrosis and cirrhosis.

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II. Study Objective
(I) Primary Objective
Use liver biopsy as “golden standard” for pathological staging, to evaluate the clinical
values of FibroTouch for the non-invasive and quantitative diagnosis of liver fibrosis and
cirrhosis in CHB patients.
(II) Secondary Objective
Difference between FibroTouch and FibroScan in the rate of d successful
detection
Difference between FibroTouch and FibroScan in the determined values
Correlation
between
determined
values
of
FibroTouch
and
ultrasonic
semi-quantitative scores
Performance of FibroTouch.
-
Positioning accuracy evaluated by investigators
-
Image displaying ability evaluated by investigators
-
Scanning speed evaluated by investigators
-
Detecting and calculating speed evaluated by investigators
III. Study Goal
To determine the diagnostic accuracy, specificity and sensitivity of FibroTouch for liver
fibrosis assessment in CHB patients.
IV. Study Type
It’s a prospective and multicenter study.
V. Anticipated Total Cases
According to publications on FibroScan and liver biopsy examination, the mean
sensitivity and specificity are 0.61 and 0.90 respectively for different stages (four pathological
stages: ≥F4, ≥F3, ≥F2 and F0-F1). Assuming a similar sensitivity and specificity of
FibroScan and FibroTouch, the lowest clinically acceptable sensitivity and specificity is 0.55

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and 0.8 respectively, when α=0.05 and power=80%, 423 cases are required based on
sensitivity; total 529 cases are required based on the determination effectiveness=80%; 328
cases are required based on specificity; total 410 cases are required based on the
determination effectiveness=80%. By considering the center assignment, ≥600 qualified cases
are included to guarantee 500 final statistical cases; and ≥100 cases are required for S0+S1,
S2, S3, S4 and liver cirrhosis (compensatory stage) respectively. For each stage, the case is
assigned as equally as possible.
VI. Study Time
One year (from May 2014 to May 2015).
VII. Case Assignment System (via central registration system)
Subject No. is assigned through IWRS system. After the investigator logs in the system
and fills in the pathological stages, this system will, according to the completed contents,
automatically assign the sole subject No. for this subject.
VIII. Statistical Analysis
Peking University Clinical Research Institute
IX. Study Design
(I) Inclusion Criteria
1. Age: 18－65 years, both gender.
2. History of HBV or HBsAg positive > 6 months up to now.
3. With qualified liver biopsy within three months before or after Fibrotouch examination
for pathological staging.
4. Without chemical therapy history of powerful medicine to lower enzyme in the two
weeks before blood biochemistry tests (e.g. dimethyl diphenyl bicarboxylate and
bicyclol).
5. Participant agreed and signed the informed consent form.
(II) Exclusion Criteria
1. The people who are unable or unwilling to sign informed consent form.

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2. The people who have merger of hepatitis c, alcohol and non-alcoholic fatty liver
disease, autoimmune liver disease, inherited metabolic liver disease, biliary systemic
disease or liver and gall parasitic diseases.
3. The people who have other serious chronic disorders or history of malignancy.
4. The people with ALT ≥5 ULN in the past 1 month.
5. The people with WBC＜3.5×109/L, PLT＜60×109/L, PTA＜60％.
6. The people with DBIL≥1.5 ULN.
7. The people with decompensated cirrhosis (especially the people with ascites).
8. Pregnant or lactating women, or women who has a pregnant plan and don't want to
birth control in the study period.
9. The people who have wound on the right upper abdomen recently.
10. The people who have various space-occupying tumor or cyst in right liver.
11. The people who have none or limited legal capacity.
(III) Study method
1. Outpatients and inpatients with chronic hepatitis B and compensatory liver cirrhosis,
conforming to the inclusion criteria and signing the ICF.
2. Collection of materials and specimen:
◆
Collection of clinical materials: Fill in the uniformly-printed CRF and keep or
duplicate the original medical record.
(1) Name, sex, age, illness course, family history of infectious diseases and hereditary
diseases, drinking history, pharmacotherapy history, and history of chronic diseases (e.g.
essential hypertension, heart disease and diabetes).
(2)
Physical
examination:
Height
(cm),
weight
(kg),
body
mass
index
(BMI=weight/height2), heart rate (bpm), respiratory rate (times/min), blood pressure (mmHg).
◆
Retaining of hematological specimen: Within one week before the FibroTouch
examination, the venous blood is drawn at an empty stomach, and the different portions of

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blood are kept: 2ml whole blood (freeze in two 2ml tubes); 8ml completely-separated serum
(freeze in four 2ml tubes); and 3ml plasma (freeze in two 2ml tubes). Keep the tube at -80℃,
and uniformly send it to the central laboratory.
◆
Retaining of liver puncture specimen: Fix with 10% neutral formalin, retain
additionally 6 white films at every unit, and send it to the pathological examination center (the
quality control is shown in Appendix 1).
3. Hematological examination: (the quality control is shown in Appendix 1)
(1) Routine blood tests;
(2) PT, PTA, INR;
(3) TP, ALB, AST, ALT, CHE, GGT, ALP, TBA, TBIL, DBIL, GLU, TC, TG, HDL, LDL,
BUN, Cr;
(4) AFP;
(5) Serum virological indices: hepatitis B test (five-item), HBV-DNA assay, HCV
antibody test, HIV antibody test; HDV antigen test.
4. Ultrasonic examination:
Within three months after the liver biopsy, the ultrasonic examination is made at an
empty stomach for ≥8h. The inner diameter of liver, spleen, gallbladder, portal vein and
splenoportal vein is measured through the ordinary two-dimensional ultrasonic examination.
The echo data of liver surface/edge/parenchyma and gallbladder wall is scored to evaluate the
severity of fibrosis. At every center, the operation should be made via the fixed machine by
the fixed person, so as to prevent the artificial error; and the ultrasonic examination, the
elasticity determination of liver tissues and the collection of medical history should be made
in the same day.
Semi-quantitative Scoring Criteria at Liver Ultrasonic Examination
Score
Item
1 score
2 scores
3 scores
Liver surface
(Ls)
Smooth, flat
Unsmooth, fine water
ripple
Wave, saw-shaped or
discontinuous
Liver
parenchyma
(Lp)
Fine spot,
uniform
distribution
Slightly enhanced,
coarse particle of
non-uniform
Obviously echo
enhanced, particulate
or nodular echo group

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distribution
Gallbladder
wall (G)
Smooth
Coarse, slightly
thickened
Obviously thickened or
two-side sign
5. Liver Stiffness Measurement (LSM)
Within 3 months before and after the liver biopsy, the liver stiffness measurement (LSM)
values are determined via FibroTouch.
◆
Investigators will operate the FibroTouch system to measure the patients’ values of
liver stiffness and fat attenuation parameters according to the SOP of FibroTouch.
<1>. Subjects lie in face-up position, and stretch his or her right arm to the maximum
extent or cross behind his or her head. Enter the name, gender, birth date, medical card No.,
height, weight and other information into patient information log in FibroTouch system.
<2>. In order to determine accurately, image-guided positioning with ultrasonic B probe
should be performed prior to the scanning with liver fibrosis probe. Apply ultrasonic coupling
agent to the patient’s skin at the position of right side, interspace between the Seventh and
eighth rib along the midaxillary line, place the ultrasonic B probe perpendicularly on the skin,
and then turn on the FibroTouch image-guided scanning model. Investigator can choose the
proper position for liver examination with reference to the ultrasonic B image on the video
display screen.
The testing position (at the center line of ultrasonic B image) is selected as following
roles:
1.
Be away from the heterogeneous liver tissues, such as great vessels, cysts and
nodes.
2.
Be away from the edge of liver.
3.
The position where liver tissue are homogeneous, well-proportioned and with
thickness no less than 7cm.
<3>. Save the ultrasonic B image, hang off ultrasonic B probe from the selected position,
and change to liver fibrosis scanning model. Hold the fibrosis scanning probe in right hand,
bend forefinger to keep probe perpendicularly at the selected position on the skin, lie right
elbow on the bed (to avoid the right arm from shaking and moving), and left hand hold the tail
of the probe to control the direction. Press the probe slightly on patients’ skin to make the
pressure indicating strip turn green.
<4>. With subject holding his or her breath slightly, operator observes the liver tissue
displayed by ultrasonic-M signal. When the tissue is dark, more homogeneous and laminar
distribution, the operators can press down the foot switch, and the fibrosis scanning probe sent
out low-frequency shear waves for diagnosing and ultrasonic waves for monitoring, the probe
is activated and complete once examination of LSM.
<5>. Ten times of successful detection are performed at the same position. When the inter

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quartile range (IQR) value is qualified, the median value of these detections will be
considered as the examination result of LSM.
<6>. Save and print the test result.
◆
The operator of FibroTouch must be trained by Hisky and obtain an operating
license or certificate.
◆
A successful and effective test by FibroTouch must meet the following requirements:
ultrasonic-A signal does not have intensive and rapid shaking, and does not fluctuate
significantly in different depth; ultrasonic-M signal does not have big difference of lightness
and displays a laminar distribution pattern in different depth; ultrasonic-E signal presents a
routine white-and-black twill diagram.
◆
Each subject will obtain 10 successful acquisitions and the median value of these
acquisitions will be considered as the examination result of LSM and FAP. The
IQR-to-median ratio of the 10 acquisitions should be ≤0.3 (the smaller the IQR value, the
reliable the result is). If the result is not reliable, it should be detected again until the result is
reliable.
◆
To avoid artificial errors, the instrument needs to be operated by a fixed
professional in each site, and all information will be documented in a uniform model and
stored in U-disk, keep by a designated personnel.
6. FibroScan Examination
6.1 At the same site as that for FibroTouch, the stiffness of liver is determined via
Fibroscan at the same day.
6.2 Operation procedure
(1) Keep in a supine position, lift up both hands to expose the intercostal gap in the area
of right liver lobe of chest, and take a deep breath to make the intercostal gap as large
as possible at the time of determination.
(2) Vertically stick the probe smeared with coupling agent to the intercostal gap.
(3) Determination site: Select the intercostal gap at the anterior or middle axillary line
between the Rib 8~10 for routine determination, or adjust the determination site
until the optimal one according to the real-time audiovisual diagram if the
determination fails at the routine site.
(4) Observe the audiovisual diagram displayed in the instrument, and press the emission
button for determination when there is a laminar liver image.

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(5) Determine effectively for 10 times, and regard the mean of these 10 determinations as
the determination result.
7. Liver biopsy
Within 3 months before the FibroTouch examination, puncture the 16G liver biopsy
needle into 1.5~2.0cm of liver tissues (≥8 complete portal areas), fix with 10% neutral
formalin, embed with paraffin wax, make the continuous section for HE, Masson and reticular
fiber staining (make the HE staining at every study unit, and send another 6 white films to the
central laboratory). Then, three pathologists interpret the films independently according to the
standard and modified Chevallier semi-quantitative scoring method in the “Protocol for
Prevention and Treatment of Viral Hepatitis (2001)”. The interpretation result of these three
pathologists should be verified as well consistent through the Kappa test, and otherwise the
specimen of inconsistent interpretation result is sent for central interpretation and evaluation.
(1) The liver fibrosis is staged and scored through the following protocol:
①National Protocol for Prevention and Treatment of Viral Hepatitis (2000): staging of
liver fibrosis
②Chevallier System (SSS scoring)
③Metavir System
④Ishak System
(2) Evaluation protocol for inflammatory activity level and histological activity index
(HAI):
①National Protocol for Prevention and Treatment of Viral Hepatitis (2000): grading of
inflammation severity
②Ishak Modified HAI: ____/18 (maximum score)
③METAVIR System: histological activity score
(IV) Safety Evaluation
1. Clinical Safety Evaluation
The clinical safety is evaluated through the adverse events reported by the patients or
observed by the doctors.

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2. AE
Definition: Any adverse medical event reported by the patients or observed by the
doctors from the signing of ICF and recruitment into study to the final follow-up, either at a
causality correlation with the study device or not.
(1) AE record
During the study, the occurrence time of AE, its correlation with study device, its
severity, duration, countermeasures and prognosis should be recorded strictly by the facts.
The AEs should be recorded into the assigned CRF of adverse events.
(2) Judgment criteria for AE severity
◆
While filling in the CRF, the investigators will describe the intensity of AE in the
following grading criteria:
Mild: No influence on the normal function of subjects;
Moderate: A certain influence on the normal function of subjects;
Serious: Obvious influence on the normal function of subjects.
(3) Judgment criteria for correlation between AE and study device
The investigators should evaluate the possible correlation between AE and study device
in the following principles:
①
Whether there is a rational precedence relation between the starting time of
FibroTouch examination and the occurrence time of AE;
②Whether the suspicious AE conforms to the known type of AE for this device;
③Whether the suspicious AE can be interpreted by the clinical state of patients or the
influence of other therapies;
④Whether the AE disappears or is relieved after the suspension of examination.
According to the above principles, the correlation is classified into 5 grades: definitely
relevant, probably relevant, possibly relevant, possibly irrelevant and irrelevant.
(4) SAE:
◆Judgment of SAE: Under one or more following conditions, the AE is regarded as a
SAE: ①
Death; ②
Life-jeopardizing (e.g. risk of immediate death); ③
Induced or
prolonged hospitalization;
④
Influenced working ability;
⑤
Permanent or serious

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disability; ⑥
Congenital malformation or defect. If a certain medical event of no death,
life-jeopardization or hospitalization may harm the patient or require the medicines or surgery
to prevent the occurrence of above conditions in the viewpoint of study doctor, such event
should also be regarded as SAE.
◆Treatment of SAE: If the AE is irrelevant to study device and does not seriously
influence the patient and the patient can be followed up as scheduled, the study should be
continued. Under the other conditions, the patient should drop out.
◆Recording and reporting of SAE: Any SAE during this study should immediately be
reported to the supervisor, sponsor and national medicine clinical study institution (i.e.
leading unit), which should report to the Ethic Committee and then within 24h to the CFDA
and health administrative departure Meanwhile, the investigators must fill in the “Reporting
Form of Serious Adverse Events”, and record the occurrence time, severity, duration,
countermeasures and prognosis of SAE. If a patient suddenly dies during the study, such
event should be reported as SAE, and the autopsy report should be enclosed if any.
(V) Quality Control and Quality Assurance of Clinical Study
◆The participants must pass the uniform training on the uniform recording method and
judgment criteria.
◆
The investigators must work strictly according to this protocol, fill in all study
materials in an accurate timely complete neat way, so as to ensure the true reliable contents of
report.
◆Any observation result and finding during this study should be verified so as to
ensure the reliability of data and guarantee that every conclusion of clinical study stems from
raw data. At the stage of clinical study and data processing, there should be corresponding
measures for data management.
◆During this study, the clinical supervisor will regularly or irregularly make the field
supervisory visit to the study center. According to the relevant regulations, the supervisor has
the right to check the original record and remind/urge the investigators to carefully
normatively complete the study work; and the investigators are liable to coordinate with such
work.

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(VI) Ethical Requirements and Informed Consent
◆No subject can be enrolled in the study before he or she express his/her willingness to
participate in this study in written statement. To make this decision, subjects should be
informed of content of this study and the potential risks and benefits involved.
The investigator must inform this information in both spoken and written form.
Informed
consent
should
be
obtained
from
the
participants
(or
legally
authorized
representative or Witness, if applicable) prior to any other study assessment. A copy of the
signed Informed consent form (ICF) will be given to patients.
After signed ICF, the subject’s investigational data can be collected. The information in
ICF involved in clinical study may be released and monitored by the Sponsor, device
regulatory authorities, designated auditors and monitors according to the confidentiality
statement.
◆The following information should be told to the patient: objective and procedure of
study; benefits and possible side effects for participation into the clinical study; the privacy of
each patient should be protected; and at any study-related injury during this study, the
investigators will give the active treatment and the sponsor will make the proper
compensation.
◆
Before the initiation of this study, the permission of Ethic Committee should be
obtained, and the written certificate for such permission should also be obtained. According to
the guideline of GCP, this protocol can be modified only after the permission of Ethic
Committee. If such modification may endanger the patient, the contents of ICF should be
updated, and the signed consent should be obtained from the participating patients. This study
should observe the Helsinki’s Declaration and national specifications/regulations on clinical
study, and can be made only after the permission of relevant institutions.
(VII) Statistical Analysis of Data
After the determination of study protocol, the statisticians should discuss with the
principal investigator on preparing the statistical analytical plan. The data is analyzed through
the statistical software SAS 9.3 (authorization No.: 11202165). The sample size is calculated
through the software PASS 11. The contents of statistical analysis are classified into the

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following parts:
1. Basic description: Age, sex, medical history and relevant indices of laboratory
examination (e.g. ALT and AST). For the quantitative indices, the mean, standard deviation,
median, minimum value, maximum value, lower quartile (Q1) and upper quartile (Q3) will be
described; and for the classification indices, the case amount and percentage in each category
will be described.
2. Evaluation of diagnostic ability via elasticity determination result
◆
By grouping according to the grading result via golden standard, the inter-group
comparison is made on the FibroTouch determination results through the variance analysis or
Wilcoxon rank-sum test, the correlation between two groups is tested through the Spearman
correlation analysis, and the correlation coefficient (r) and 95% CI are calculated for two
groups.
◆By regarding the different grading results of golden standard as the judgment critical
point, the curve of receiver operating characteristic (ROC) for elasticity value is constructed.
The subjects are grouped by regarding the different determination results of elasticity value as
the judgment critical point, the sensitivity/specificity is calculated according to the grading
result of golden standard, the ROC curve is plotted through the X-axis of specificity, the
Y-axis of sensitivity and the calculated result, and the area under curve and its 95%
confidence interval are calculated. The critical value corresponding to whichever is greater
for the result of sensitivity and specificity is regarded as the judgment critical point for
FibroTouch determination value, and then the corresponding sensitivity, specificity, positive
predicted value and negative predicted value are calculated.
Comparison of secondary objective: by statistically assuming the success rate of
FibroTouch is non-inferior to that of Fibroscan, the critical value of non-inferiority is 10%;
and by statistically assuming the determination result of FibroTouch is equivalent to that of
Fibroscan, the critical value of equivalence is 1.5KPa.
In the above analysis, P<0.05 indicates a significant difference.
(VIII) Data Management and Data Traceability
8.1 Data center

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The
Data
Management
Dept
of
Peking
University
Clinical
Research
Institute
(PUCRI-DM) undertakes the work of project data management.
8.2 CRF design and electronic database construction
According to the CRF template of PUCRI, the investigators draft the study CRF, which
is sent to PUCRI-DM for revising the data management draft. After the confirmation of
investigators and the signing of investigators, PUCRI-DM and statisticians, the final version
is prepared into CRF 1.0.
Based on CRF 1.0, PUCRI-DM constructs the electronic data collection system
(Real-data RDDM v1.0), which supports the electronic signature, authority control and trace
management.
8.3 Data management plan and data verification plan
In this study, PUCRI-DM drafts the “Data Management Plan” and “Data Verification
Plan”.
The Data Management Plan describes the detail/schedule of data management work and
the duty division of each party concerned for the whole course of this project. After the
finalization of study protocol by the PUCRI-DM, investigators and supervisors, this plan is
finalized by signing before the project initiation.
The Data Verification Plan describes the detail of project data verification. It is drafted
by the PUCRI-DM after the finalization of study protocol and study CRF, and reviewed by
the investigators. In this plan, the point and method of data verification are determined one by
one according to the study protocol and the specific contents of CRF.
Based on the Data Verification Plan, the data verification is constructed through the
electronic data collection system.
8.4 Input and modification of data
The investigator is responsible to input and modify the data, and answer the data
question in field. Through the Real-data RDDM v1.0, the investigator inputs the electronic
data of personal system account, and answers via the system the data questions raised by the
data administrator or supervisors. The input data and question answer of investigators are
traceable and kept in the system.

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8.5 Data Monitoring
Through the account of project supervisor, the supervisors clinically supervise the study
data through the following procedures: check the complete and correct filling of electronic
data through the EDC system; compare the electronic data with materials in original medical
history; and query the investigators on the data point of inconsistency (if any) which is
submitted for modification or confirmation. All data questions and checking records are
traceable and kept in the system.
8.6 Data Verification And Data Management
Through the account of administrator, the data administrator checks the completeness
and logic question of input data. At any doubt on data, the data question is raised to the
investigators.
8.7 Database Locking and Data Review
After the inputting of data of all subjects, the investigators coordinate in clearing all
residual data questions, the supervisors completes the checking of original medical history,
then some authorities are closed (i.e. data input/modification of investigators and data query
of supervisors and data administrator), and the study data is frozen so as to guarantee the
stability of study data.
After the freezing of database, the “Data Management Report” is drafted by the
PUCRI-DM and submitted to the data review meeting, and then the possible data in this
report is solved at the simultaneous presence of investigators, statisticians and PUCRI-DM,
and the statistical population is divided.
If the frozen database is confirmed as no data question by the investigators, the database
is locked and unblended after the division of statistical population is confirmed.
X. Anticipated Schedule of Clinical Study
Conference on the FibroTouch clinical protocol: December 2013 ~ January 2014.
Training on the operation of FibroTouch ultrasonic diagnostic device: February ~ March
2014
Clinical study on FibroTouch ultrasonic diagnostic device: May 2014 ~ May 2015

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Appendix 1: Quality Control of Central Laboratory
I. Hematological Determination
1. Collection of specimen
2. Determination of specimen
Each laboratory should complete the hematological, coagulation and clinical chemical
examinations within 2h, and complete the virological examination within 2 weeks.
(1) Hematological examination (whole blood, 18-item)
(2) Coagulation examination (PT, PTA and INR)
(3) Clinical chemical examination (TP, ALB, TBIL, DBIL, AST, ALT, TBA, ALP, GGT,
CHE, GLU, TC, TG, HDL, LDL, BUN, CR and AFP).
For the above examination items, the fully-automatic blood analyzer and matching
reagents of Beckman Culter and Sysmex Co. are recommended. The requirements of quality
control are shown in the quality control of Clinical Examination Center, the Ministry of
Health.
(4) Serum virological examination (HBV-DNA, hepatitis B test (5-item), HCV antibody
test, HDV antigen test, HDV antibody test and HIV antibody test).
The hepatitis B test (5-item) is made through the fully-automatic chemiluminescent
device and its matching reagents (e.g. Roche and Abbort Co.); the
HBV-DNA assay is made
through the real-time fluorimetric reagents with the registration certificate of China Food and
Drug Administration and the quality control qualification certificate of Clinical Examination
Center, the Ministry of Health and through the fully-automatic real-time fluorometric PCR
analyzer with the registration certificate (e.g. Roche and AB Co.); the hepatitis C antibody test
is made through the fully-automatic chemiluminescent device and its matching reagents (e.g.
Ortho Johnson ECI and Abbort); and the hepatitis D antibody test and HIV antibody test are
made primarily through the imported reagents and secondarily through the China-made ones
according to the conditions of each unit. The requirements of quality control are shown in the
quality control of Clinical Examination Center, the Ministry of Health.
2. Treatment, storage and transportation of specimen
Treatment: The collected specimen should be immediately sent to the laboratory of each

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unit, and treated in time by special person after the receipt of specimen, including: specimen
No. and centrifuged or separated serum.
Storage: Before the test operation, the serum should be retained at each laboratory, i.e.
fill 2ml serum in the air-tight tube, and then keep at -80℃ready for random inspection. The
specimen sent to the central laboratory for uniform examination (relevant indices for liver
fibrosis) should be numbered via the uniformly-colored symbol by the special person, and the
different portions of blood are kept: 2ml whole blood (freeze in two 2ml tubes); 8ml
completely-separated serum (freeze in four 2ml tubes); and 3ml plasma (freeze in two 2ml
tubes). Keep the tube at -80℃, and record properly (basic information of patients).
Transportation: The specimen sent to the central laboratory for uniform examination
should be sent as centrally as possible (monthly) at the frozen and sealed state (i.e. keep in the
freezing tube, and transport via the dry-ice storage box) by avoiding the repeated
freezing/melting and the specimen sprinkling/leakage.
II. Liver Biopsy
1. Selection criteria for liver puncture specimen
The specimen of liver tissues should be punctured generally at more than 2.0~2.5cm
(including >8 intact duct convergence areas) and at least 1cm.
2. Treatment specifications or procedures for liver puncture specimen
After the fixation, dehydration, transparency, paraffin soaking/embedding and section,
the specimen of liver puncture tissues undergo the routine HE staining, Gordon-Sweet
reticular staining and Massson staining.
Specifications and procedures:
Rapidly put the puncture liver tissues into the specimen bottle full of 10% neutral
formalin buffer solution, fix at the ordinary temperature for 3h, and mark the name
abbreviation, department and case No. of patients on the specimen bottle.
Notes: Do not compress the specimen while clamping the specimen with the nippers so
as to prevent the mechanical specimen damage. Do not adopt the toothed nippers. Collect the
tissue specimen at an intact state as far as possible.
3. Histological evaluation criteria

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(1) Pathological diagnostic criteria for chronic hepatitis specified in the “Protocol of
Prevention and Treatment of Viral Hepatitis (2001)” jointly revised by the Society of
Infectious and Parasitic Diseases and the Society of Liver Diseases under the Chinese
Medical Association in September 2000.
(2) Scoring of inflammatory activity level of chronic hepatitis and severity of liver
fibrosis through the international scoring criteria for chronic hepatitis (Ishak).
(3) Final histological evaluation by 3 experienced pathological experts.

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Appendix 2: Flow Chart of Study Design
Blood drawing, ultrasonic B
examination, FibroScan,
physical examination after
the informed consent
Pathological staging
Statistical analysis
FibroTouch examination:
LSM
The CHB patients with liver fibrosis and liver
cirrhosis have underwent the liver biopsy and
signed the ICF
Meets the inclusion criteria
Central registration
Rejections of the patients not
meet the inclusion criteria
Existing liver biopsy specimens
Final pathological staging

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Appendix 3: Knodell System: a scoring system for liver histological activity index (HAI)
Necrosis around
the convergence
duct
Score
Degeneration and
focal necrosis in the
liver lobule
Score
Inflammation in
the duct
convergence area
Score
Liver fibrosis
Score
No
0
No
0
No
0
No
0
Mild flaky
necrosis
1
Mild (scattered
necrosis foci of liver
cells in the
eosinophilic
corpuscle, ballooning
degeneration and/or
1/3 of nodes)
1
Mild
(inflammatory
cells in 1/3 of duct
convergence area)
1
Fibrous
expansion of duct
convergence area
1
Moderate flaky
necrosis
(involving <50%
of area around
the duct
convergence)
3
Moderate (involving
Involve 1/3~2/3 of
liver lobules or
nodes)
3
Moderate
(increase of
inflammatory
cells in 1/3~2/3 of
duct convergence
area)
3
Bridged fibrous
connection
(between the duct
convergence
areas or between
the duct
convergence area
and
central
vein)
3
Obvious flaky
necrosis
(involving >50%
of area around
the duct
convergence)
4
Obvious
(involving >2/3 of
liver lobules or
nodes)
4
Obvious (increase
of inflammatory
cells in >2/3 of
duct convergence
area)
4
Liver cirrhosis
4
Moderate flaky
necrosis +
bridged necrosis
5
Obvious flaky
necrosis +
bridged necrosis
6
Multi-lobular
necrosis
10

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Appendix 4: Evaluation Protocol for Staging and Scoring of Liver Fibrosis
Stage
Knodell
Ishak
Scheuer
METAVIR
0
No fibrosis
No fibrosis
No fibrosis
No fibrosis
1
Expansion of duct
convergence area
Some PFs ±
short fibrous
gaps
Expansion of
duct
convergence
area
PF, but no
fibrous gap
2
Most PFs ± short fibrous
gaps
PF, formation
of fibrous gap
PF, a few
gaps
PF, a few gap
fibrosis
3
Bridged fibrosis
P-P/P-C
Most PFs,
occasional P-P
Fibrous gap
with nodular
structural
disorder
Gap fibrosis
4
Liver cirrhosis
PF with
obvious P-P
and P-C
Possible or
definite liver
cirrhosis
Liver cirrhosis
5
Obvious
P-P/P-C,
occasional
node
6
Possible or
definite liver
cirrhosis