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Maybury C, Samarasekera E, Douiri A, Barker J, Smith C. Diagnostic accuracy of noninvasive markers of liver fibrosis in patients with psoriasis taking methotrexate: a systematic review and meta-analysis. Br J Dermatol 2014; 170:1237-47. [DOI: 10.1111/bjd.12905] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2014] [Indexed: 01/06/2023]
Affiliation(s)
- C.M. Maybury
- St John's Institute of Dermatology; Division of Genetics and Molecular Medicine; Guys Campus; King's College London; London U.K
| | - E. Samarasekera
- National Clinical Guideline Centre; Royal College of Physicians of London; 11 St Andrews Place London NW1 4LE U.K
| | - A. Douiri
- Department of Public Health Sciences; School of Medicine; King's College London; Capitol House; 42 Weston St London SE1 3QD U.K
| | - J.N. Barker
- St John's Institute of Dermatology; Division of Genetics and Molecular Medicine; Guys Campus; King's College London; London U.K
| | - C.H. Smith
- St John's Institute of Dermatology; Division of Genetics and Molecular Medicine; Guys Campus; King's College London; London U.K
- St John's Institute of Dermatology; Guys and St Thomas' NHS Foundation Trust; London U.K
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102
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Martyn-Simmons C, Rosenberg W, Cross R, Wong T, Smith C, Barker J. Validity of noninvasive markers of methotrexate-induced hepatotoxicity: a retrospective cohort study. Br J Dermatol 2014; 171:267-73. [DOI: 10.1111/bjd.12782] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2013] [Indexed: 01/06/2023]
Affiliation(s)
- C.L. Martyn-Simmons
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - W.M.C. Rosenberg
- Division of Medicine; Institute for Liver and Digestive Health; University College London; London U.K
| | - R. Cross
- iQur Ltd; Wolfson Laboratory; Royal Free Hospital; London U.K
| | - T. Wong
- Department of Gastroenterology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - C.H. Smith
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - J.N.W.N. Barker
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
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103
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Ali AH, Carey EJ, Lindor KD. An overview of current and future therapeutic strategies for the treatment of primary sclerosing cholangitis. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.908701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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104
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Trembling PM, Lampertico P, Parkes J, Tanwar S, Viganò M, Facchetti F, Colombo M, Rosenberg WM. Performance of Enhanced Liver Fibrosis test and comparison with transient elastography in the identification of liver fibrosis in patients with chronic hepatitis B infection. J Viral Hepat 2014; 21:430-8. [PMID: 24750297 PMCID: PMC4298014 DOI: 10.1111/jvh.12161] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Assessment of liver fibrosis is important in determining prognosis, disease progression and need for treatment in patients with chronic hepatitis B (CHB). Limitations to the use of liver biopsy in assessing fibrosis are well recognized, and noninvasive tests are being increasingly evaluated including transient elastography (TE) and serum markers such as the Enhanced Liver Fibrosis (ELF) test. We assessed performance of ELF and TE in detecting liver fibrosis with reference to liver histology in a cohort of patients with CHB (n = 182), and compared the performance of these modalities. Median age was 46 and mean AST 70 IU/L. Cirrhosis was reported in 20% of liver biopsies. Both modalities performed well in assessing fibrosis at all stages. Area under receiver operator characteristic (AUROC) curves for detecting METAVIR fibrosis stages F ≥ 1, F ≥ 2, F ≥ 3 and F4 were 0.77, 0.82, 0.80 and 0.83 for ELF and 0.86, 0.86, 0.90 and 0.95 for TE. TE performed significantly better in the assessment of severe fibrosis (AUROC 0.80 for ELF and 0.90 for TE, P < 0.01) and cirrhosis (0.83 for ELF and 0.95 for TE, P < 0.01). This study demonstrates that ELF has good performance in detection of liver fibrosis in patients with CHB, and when compared, TE performs better in detection of severe fibrosis/cirrhosis.
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Affiliation(s)
- P M Trembling
- Institute for Liver and Digestive Health, Division of Medicine, University College LondonLondon, UK
| | - P Lampertico
- AM and A Migliavacca Center for Liver Disease, 1st Division of Gastroenterology, Department of Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di MilanoMilan, Italy
| | - J Parkes
- Public Health Sciences and Medical Statistics, Faculty of Medicine, University of SouthamptonSouthampton, UK
| | - S Tanwar
- Institute for Liver and Digestive Health, Division of Medicine, University College LondonLondon, UK
| | - M Viganò
- AM and A Migliavacca Center for Liver Disease, 1st Division of Gastroenterology, Department of Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di MilanoMilan, Italy,UO Epatologia, Ospedale San Giuseppe, Università degli Studi di MilanoMilan, Italy
| | - F Facchetti
- AM and A Migliavacca Center for Liver Disease, 1st Division of Gastroenterology, Department of Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di MilanoMilan, Italy
| | - M Colombo
- AM and A Migliavacca Center for Liver Disease, 1st Division of Gastroenterology, Department of Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di MilanoMilan, Italy
| | - W M Rosenberg
- Institute for Liver and Digestive Health, Division of Medicine, University College LondonLondon, UK
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105
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Abstract
Liver fibrosis is the final common pathway for almost all causes of chronic liver injury. Liver fibrosis is now known to be a dynamic process having significant potential for resolution. Therefore, fibrosis prediction is an essential part of the assessment and management of patients with chronic liver disease. As such, there is strong demand for reliable liver biomarkers that provide insight into disease etiology, diagnosis, therapy, and prognosis in lieu of more invasive approaches such as liver biopsy. Current diagnostic strategies range from use of serum biomarkers to more advanced imaging techniques including transient elastography and magnetic resonance imaging. In addition to these modalities, there are other approaches including the use of novel, but yet to be validated, biomarkers. In this chapter, we discuss the biomarkers of liver fibrosis including the use of invasive and noninvasive biomarkers and disease-specific biomarkers in various chronic liver diseases.
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106
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Kim MY, Jeong WK, Baik SK. Invasive and non-invasive diagnosis of cirrhosis and portal hypertension. World J Gastroenterol 2014; 20:4300-4315. [PMID: 24764667 PMCID: PMC3989965 DOI: 10.3748/wjg.v20.i15.4300] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/20/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
With advances in the management and treatment of advanced liver disease, including the use of antiviral therapy, a simple, one stage description for advanced fibrotic liver disease has become inadequate. Although refining the diagnosis of cirrhosis to reflect disease heterogeneity is essential, current diagnostic tests have not kept pace with the progression of this new paradigm. Liver biopsy and hepatic venous pressure gradient measurement are the gold standards for the estimation of hepatic fibrosis and portal hypertension (PHT), respectively, and they have diagnostic and prognostic value. However, they are invasive and, as such, cannot be used repeatedly in clinical practice. The ideal noninvasive test should be safe, easy to perform, inexpensive, reproducible as well as to give numerical and accurate results in real time. It should be predictive of long term outcomes related with fibrosis and PHT to allow prognostic stratification. Recently, many types of noninvasive alternative tests have been developed and are under investigation. In particular, imaging and ultrasound based tests, such as transient elastography, have shown promising results. Although most of these noninvasive tests effectively identify severe fibrosis and PHT, the methods available for diagnosing moderate disease status are still insufficient, and further investigation is essential to predict outcomes and individualize therapy in this field.
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107
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Xie Q, Zhou X, Huang P, Wei J, Wang W, Zheng S. The performance of enhanced liver fibrosis (ELF) test for the staging of liver fibrosis: a meta-analysis. PLoS One 2014; 9:e92772. [PMID: 24736610 PMCID: PMC3988013 DOI: 10.1371/journal.pone.0092772] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/26/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The enhanced liver fibrosis test (ELF) has been shown to accurately predict significant liver fibrosis in several liver diseases. AIMS To perform a meta-analysis to assess the performance of the ELF test for the assessment of liver fibrosis. STUDY Electronic and manual searches were performed to identify studies of the ELF test. After methodological quality assessment and data extraction, pooled estimates of the sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and summary receiver operating characteristics (sROC) were assessed systematically. The extent of heterogeneity and reasons for it were assessed. RESULTS Nine studies were identified for analysis. The pooled sensitivity, specificity, positive LR, negative LR, and DOR values of ELF test, for assessment of significant liver fibrosis, were 83% (95% CI=0.80-0.86), 73% (95% CI=0.69-0.77), 4.00 (95% CI=2.50-6.39), 0.24 (95% CI=0.17-0.34), and 16.10 (95% CI=8.27-31.34), respectively; and, for evaluation of severe liver fibrosis, were 78% (95% CI=0.74-0.81), 76% (95% CI=0.73-0.78), 4.39 (95% CI=2.76-6.97), 0.27 (95% CI=0.16-0.46), and 16.01 (95% CI: 7.15-35.82), respectively; and, for estimation of cirrhosis, were 80% (95% CI=0.75-0.85), 71% (95% CI=0.68-0.74), 3.13 (95% CI=2.01-4.87), 0.29 (95% CI=0.19-0.44), and 14.09 (95% CI: 5.43-36.59), respectively. CONCLUSIONS The ELF test shows good performance and considerable diagnostic value for the prediction of histological fibrosis stage.
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Affiliation(s)
- Qingsong Xie
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Xiaohu Zhou
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Pengfei Huang
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Jianfeng Wei
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
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108
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Ydreborg M, Lisovskaja V, Lagging M, Brehm Christensen P, Langeland N, Buhl MR, Pedersen C, Mørch K, Wejstål R, Norkrans G, Lindh M, Färkkilä M, Westin J. A novel fibrosis index comprising a non-cholesterol sterol accurately predicts HCV-related liver cirrhosis. PLoS One 2014; 9:e93601. [PMID: 24699777 PMCID: PMC3974766 DOI: 10.1371/journal.pone.0093601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 03/05/2014] [Indexed: 12/28/2022] Open
Abstract
Diagnosis of liver cirrhosis is essential in the management of chronic hepatitis C virus (HCV) infection. Liver biopsy is invasive and thus entails a risk of complications as well as a potential risk of sampling error. Therefore, non-invasive diagnostic tools are preferential. The aim of the present study was to create a model for accurate prediction of liver cirrhosis based on patient characteristics and biomarkers of liver fibrosis, including a panel of non-cholesterol sterols reflecting cholesterol synthesis and absorption and secretion. We evaluated variables with potential predictive significance for liver fibrosis in 278 patients originally included in a multicenter phase III treatment trial for chronic HCV infection. A stepwise multivariate logistic model selection was performed with liver cirrhosis, defined as Ishak fibrosis stage 5–6, as the outcome variable. A new index, referred to as Nordic Liver Index (NoLI) in the paper, was based on the model: Log-odds (predicting cirrhosis) = −12.17+ (age×0.11) + (BMI (kg/m2)×0.23) + (D7-lathosterol (μg/100 mg cholesterol)×(−0.013)) + (Platelet count (x109/L)×(−0.018)) + (Prothrombin-INR×3.69). The area under the ROC curve (AUROC) for prediction of cirrhosis was 0.91 (95% CI 0.86–0.96). The index was validated in a separate cohort of 83 patients and the AUROC for this cohort was similar (0.90; 95% CI: 0.82–0.98). In conclusion, the new index may complement other methods in diagnosing cirrhosis in patients with chronic HCV infection.
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Affiliation(s)
- Magdalena Ydreborg
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Vera Lisovskaja
- Department of Mathematical Sciences, Chalmers University of Technology and University of Gothenburg, Gothenburg, Sweden
| | - Martin Lagging
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Mads Rauning Buhl
- Department of Infectious Diseases, Aarhus University, Aarhus, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Kristine Mørch
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Rune Wejstål
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Norkrans
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Lindh
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Martti Färkkilä
- Institute of Clinical Medicine, Department of Gastroenterology, Helsinki University, Helsinki, Finland
| | - Johan Westin
- Department of Infectious Diseases/Virology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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109
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Longo R, Baxter P, Hall P, Hewison J, Afshar M, Hall G, McCabe C. Methods for identifying the cost-effective case definition cut-off for sequential monitoring tests: an extension of Phelps and Mushlin. PHARMACOECONOMICS 2014; 32:327-334. [PMID: 24488576 PMCID: PMC4407016 DOI: 10.1007/s40273-014-0134-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The arrival of personalized medicine in the clinic means that treatment decisions will increasingly rely on test results. The challenge of limited healthcare resources means that the dissemination of these technologies will be dependent on their value in relation to their cost, i.e., their cost effectiveness. Phelps and Mushlin have described how to optimize tests to meet a cost-effectiveness target. However, when tests are applied repeatedly the case mix of the patients tested changes with each administration, and this impacts upon the value of each subsequent test administration. In this article, we present a modification of Phelps and Mushlin's framework for diagnostic tests; to identify the cost-effective cut-off for monitoring tests. Using the Ca125 test monitoring for relapse in ovarian cancer, we show how the repeated use of the initial cut-off can lead to a substantially increased false-negative rate compared with the monitoring cut-off-over 4% higher than in this example-with the associated harms for individual and population health.
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Affiliation(s)
- Roberta Longo
- Leeds Institute of Health Sciences, University of Leeds, UK
| | - Paul Baxter
- Centre for Epidemiology & Biostatistics, University of Leeds, UK
| | - Peter Hall
- Leeds Institute of Health Sciences, University of Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, UK
| | | | - Geoff Hall
- Leeds Teaching Hospitals Trust, Leeds, UK
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110
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Kang W, Kim SU, Ahn SH. Non-invasive prediction of forthcoming cirrhosis-related complications. World J Gastroenterol 2014; 20:2613-2623. [PMID: 24627597 PMCID: PMC3949270 DOI: 10.3748/wjg.v20.i10.2613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/02/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
In patients with chronic liver diseases, identification of significant liver fibrosis and cirrhosis is essential for determining treatment strategies, assessing therapeutic response, and stratifying long-term prognosis. Although liver biopsy remains the reference standard for evaluating the extent of liver fibrosis in patients with chronic liver diseases, several non-invasive methods have been developed as alternatives to liver biopsies. Some of these non-invasive methods have demonstrated clinical accuracy for diagnosing significant fibrosis or cirrhosis in many cross-sectional studies with the histological fibrosis stage as a reference standard. However, non-invasive methods cannot be fully validated through cross-sectional studies since liver biopsy is not a perfect surrogate endpoint marker. Accordingly, recent studies have focused on assessing the performance of non-invasive methods through long-term, longitudinal, follow-up studies with solid clinical endpoints related to advanced stages of liver fibrosis and cirrhosis. As a result, current view is that these alternative methods can independently predict future cirrhosis-related complications, such as hepatic decompensation, liver failure, hepatocellular carcinoma, or liver-related death. The clinical role of non-invasive models seems to be shifting from a simple tool for predicting the extent of fibrosis to a surveillance tool for predicting future liver-related events. In this article, we will summarize recent longitudinal studies of non-invasive methods for predicting forthcoming complications related to liver cirrhosis and discuss the clinical value of currently available non-invasive methods based on evidence from the literature.
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111
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Macartney MJ, Irish D, Bridge SH, Garcia-Diaz A, Booth CL, McCormick AL, Labbett W, Smith C, Velazquez C, Tanwar S, Trembling P, Jacobs M, Dusheiko G, Rosenberg W, Haque T. Telaprevir or boceprevir based therapy for chronic hepatitis C infection: development of resistance-associated variants in treatment failure. Antiviral Res 2014; 105:112-7. [PMID: 24594347 DOI: 10.1016/j.antiviral.2014.02.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/19/2014] [Accepted: 02/23/2014] [Indexed: 12/14/2022]
Abstract
The use of triple-therapy, pegylated-interferon, ribavirin and either of the first generation hepatitis C virus (HCV) protease inhibitors telaprevir or boceprevir, is the new standard of care for treating genotype 1 chronic HCV. Clinical trials have shown response rates of around 70-80%, but there is limited data from the use of this combination outside this setting. Through an expanded access programme, we treated 59 patients, treatment naïve and experienced, with triple therapy. Baseline factors predicting treatment response or failure during triple therapy phase were identified in 58 patients. Thirty seven (63.8%) of 58 patients had undetectable HCV RNA 12weeks after the end of treatment. Genotype 1a (p=0.053), null-response to previous treatment (p=0.034), the rate of viral load decline after 12weeks of previous interferon-based treatment (p=0.033) were all associated with triple-therapy failure. The most common cause of on-treatment failure for telaprevir-based regimens was the development of resistance-associated variants (RAVs) at amino acids 36 and/or 155 of HCV protease (p=0.027) whereas in boceprevir-based regimens mutations at amino acid 54 were significant (p=0.015). SVR12 rates approaching 64% were achieved using triple therapy outside the clinical trial setting, in a patient cohort that included cirrhotics.
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Affiliation(s)
- Malcolm J Macartney
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - Dianne Irish
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Simon H Bridge
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Ana Garcia-Diaz
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Clare L Booth
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Adele L McCormick
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Wendy Labbett
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Colette Smith
- Department of Population Studies, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Carmen Velazquez
- Directorate of Hepatology, Nephrology and Transplantation, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Sudeep Tanwar
- UCL Institute for Liver and Digestive Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Paul Trembling
- UCL Institute for Liver and Digestive Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Michael Jacobs
- Directorate of Hepatology, Nephrology and Transplantation, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - Geoff Dusheiko
- Directorate of Hepatology, Nephrology and Transplantation, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
| | - William Rosenberg
- Directorate of Hepatology, Nephrology and Transplantation, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom; UCL Institute for Liver and Digestive Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Tanzina Haque
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom
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112
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Czaja AJ. Review article: The prevention and reversal of hepatic fibrosis in autoimmune hepatitis. Aliment Pharmacol Ther 2014; 39:385-406. [PMID: 24387318 DOI: 10.1111/apt.12592] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 11/29/2013] [Accepted: 12/05/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immunosuppressive treatment of autoimmune hepatitis can prevent or reverse hepatic fibrosis, but these anti-fibrotic effects are inconsistent secondary gains. AIM To describe the anti-fibrotic effects of current therapies for autoimmune hepatitis, discuss the pathogenic mechanisms of hepatic fibrosis that might be targeted by anti-fibrotic interventions, indicate the non-invasive diagnostic tests of hepatic fibrosis that must be validated in autoimmune hepatitis and to suggest promising treatment opportunities. METHODS Studies cited in PubMed from 1972 to 2013 for autoimmune hepatitis, hepatic fibrosis, cirrhosis, anti-fibrotic therapy and non-invasive tests of hepatic fibrosis were selected. RESULTS Hepatic fibrosis improves in 53-57% of corticosteroid-treated patients with autoimmune hepatitis; progressive fibrosis slows or is prevented in 79%; and cirrhosis may be reversed. Progressive hepatic fibrosis is associated with liver inflammation, and the inability to fully suppress inflammatory activity within 12 months is associated with progression to cirrhosis (54%) and death or need for liver transplantation (15%). Liver tissue examination remains the gold standard for assessing hepatic fibrosis, but laboratory and radiological tests may be useful non-invasive methods to measure the fibrotic response. Severe liver inflammation can confound radiological assessments, and the preferred non-invasive test in autoimmune hepatitis is uncertain. Individualised treatment adjustments and adjunctive anti-fibrotic therapies are poised for study in this disease. CONCLUSIONS The prevention and reversal of hepatic fibrosis are achievable objectives in autoimmune hepatitis. Strategies that evaluate individualised therapies adjusted to the rapidity and completeness of the inflammatory response, and the use of adjunctive anti-fibrotic interventions, must be evaluated.
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Affiliation(s)
- A J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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113
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Affiliation(s)
- Ah Ram Sul
- Department of New Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
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114
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Crespo G, Forns X, Navasa M. [Serum markers of liver fibrosis in patients with chronic hepatitis C infection. Prognostic value of noninvasive markers of fibrosis in liver transplantation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 35 Suppl 2:17-22. [PMID: 23298655 DOI: 10.1016/s0210-5705(12)70045-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver fibrosis must be evaluated in patients with chronic hepatitis C, since its severity will affect prognosis and the indication of antiviral therapy. Combining serological markers of fibrosis in algorithms or scores can identify a substantial number of patients with significant fibrosis and most patients with liver cirrhosis, thus potentially avoiding a large number of biopsies. Although these algorithms should be interpreted with caution, due to their possible limitations, their high reproducibility, applicability and availability make them an essential tool in the current evaluation of patients with chronic hepatitis C infection. In contrast, serological markers have been found to be less effective in the diagnosis of fibrosis in the context of recurrent hepatitis C infection after liver transplantation. However, an algorithm for direct markers has shown excellent predictive ability in liver transplant recipients with hepatitis C. Consequently, this algorithm seems to be an excellent tool to establish prognosis and indicate antiviral therapy.
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Affiliation(s)
- Gonzalo Crespo
- Servicio de Hepatología, Institut de Malalties Digestives, IDIBAPS, CIBERehd Hospital Clínic, Barcelona, España
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115
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Abstract
The primary aim of antiviral therapy for chronic hepatitis C (CHC) is the prevention of progressive disease. A response to interferon (IFN) treatment is associated with an improvement in all-cause mortality and liver-related mortality from hepatitis C. Unless contraindicated, patients with CHC are thus potential candidates for treatment. Improved response rates are observed in patients with HCV genotype 1 infection treated with first-generation protease inhibitors. However, treatment with current first-generation protease inhibitors and IFN is complex and can result in appreciable adverse effects. The advent of potent, pan-genotypic all-oral direct-acting antiviral (DAA) regimens necessitates a critical examination of the immediate application of PEG-IFN, ribavirin and DAA regimens in patients with CHC. Current guidelines and position statements do not make clear recommendations, and are behind the emerging data. Some aspects of the conundrums facing physicians and patients are summarized in this Review. Cirrhosis presents an immediate threat of disease, and ideally treatment should be targeted at those patients who have advancing or advanced disease; unfortunately, a disparity exists, as response rates are reduced in patients with cirrhosis and the risks of adverse events are increased. On balance, patients with mild disease could consider deferring treatment.
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Cui XW, Friedrich-Rust M, Molo CD, Ignee A, Schreiber-Dietrich D, Dietrich CF. Liver elastography, comments on EFSUMB elastography guidelines 2013. World J Gastroenterol 2013; 19:6329-6347. [PMID: 24151351 PMCID: PMC3801303 DOI: 10.3748/wjg.v19.i38.6329] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/11/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Recently the European Federation of Societies for Ultrasound in Medicine and Biology Guidelines and Recommendations have been published assessing the clinical use of ultrasound elastography. The document is intended to form a reference and to guide clinical users in a practical way. They give practical advice for the use and interpretation. Liver disease forms the largest section, reflecting published experience to date including evidence from meta-analyses with shear wave and strain elastography. In this review comments and illustrations on the guidelines are given.
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Catanzaro R, Milazzo M, Arona S, Sapienza C, Vasta D, Arcoria D, Marotta F. Diagnostic accuracy of enhanced liver fibrosis test to assess liver fibrosis in patients with chronic hepatitis C. Hepatobiliary Pancreat Dis Int 2013; 12:500-7. [PMID: 24103280 DOI: 10.1016/s1499-3872(13)60079-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prognosis and clinical management of patients with chronic liver diseases are closely related to the severity of liver fibrosis. Liver biopsy is considered the gold standard for the staging of liver fibrosis. However, it is an invasive test sometimes related to complications. This study aimed to assess the diagnostic value of enhanced liver fibrosis (ELF) test to predict liver fibrosis in patients with chronic hepatitis C. METHODS This study included 162 patients with liver disease and 67 healthy controls. Hyaluronic acid, tissue inhibitor of matrix metalloproteinase type 1, and amino-terminal propeptide type III procollagen were measured by enzyme-linked immunosorbent assay with the ELF test ADVIA Centaur® (Siemens Healthcare Diagnostics Inc.). Fibrosis stage was determined using the Metavir scoring system. RESULTS In our study, for the diagnosis of significant fibrosis (Metavir F≥2) a cut-off value >7.72 provides a sensitivity of 93.0% and a specificity of 83.0%. The areas under the receiver operator characteristic curve, sensitivity, specificity, and positive and negative predictive values were 0.94, 93.3%, 81.0%, 93.3%, and 81.0%, respectively (P<0.001). For the diagnosis of cirrhosis (Metavir F=4) a cut-off value >9.3 provides a sensitivity of 93.0% and a specificity of 86.0%. The areas under the receiver operator characteristic curve, sensitivity, specificity, and positive and negative predictive values were 0.94, 79.1%, 90.8%, 75.6%, and 92.3%, respectively (P<0.001). CONCLUSIONS The ELF test is a promising non-invasive method for assessing liver fibrosis in patients with chronic hepatitis C. It is effective in the diagnosis of both fibrosis and cirrhosis.
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Affiliation(s)
- Roberto Catanzaro
- Department of Medical and Pediatric Sciences, Institute of Internal Medicine "A. Francaviglia", Section of Gastro-enterology, University of Catania, "G. Rodolico" Hospital, Via S. Sofia, 78-95123-Catania, Italy.
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Alboraie MA, Afifi ME, Elghamry FG, Shalaby HA, Elshennawy GE, Abdelaziz AA, Shaheen MU, Abo El-Seoud AR. Egy-score predicts severe hepatic fibrosis and cirrhosis in Egyptians with chronic liver diseases: a pilot study. HEPATITIS MONTHLY 2013; 13:e10810. [PMID: 24046790 PMCID: PMC3773216 DOI: 10.5812/hepatmon.10810] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/02/2013] [Accepted: 04/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Non-invasive methods for assessment of hepatic fibrosis are increasingly needed. Recent studies showed that combined elevation of tumor markers CA 19-9 and CA 125 is predictive of severe hepatic fibrosis or cirrhosis with high specificity. OBJECTIVES We aimed at developing a new panel of surrogate biomarkers for prediction of the stage of hepatic fibrosis by combining tumor markers with other known biomarkers of hepatic fibrosis. PATIENTS AND METHODS A total of 92 patients with different types of chronic liver diseases (chronic hepatitis B, chronic hepatitis C and autoimmune hepatitis), were prospectively enrolled in our cohort. They were subjected to: ALT, AST, GGT, ALP, total bilirubin, INR, total cholesterol, albumin, platelet count, cancer antigen 19-9 (CA 19-9), cancer antigen 125 (CA 125), cancer antigen 15-3 (CA 15-3), haptoglobin, alpha-2-macroglobulin, apolipoprotein A1, abdominal ultrasound, liver biopsy and histological staging of hepatic fibrosis using the METAVIR system. RESULTS Combined elevation of CA 19-9 and CA 125 with a summated value > 37 U/mL is predictive of severe hepatic fibrosis or cirrhosis (stage F3-F4 METAVIR) with a probability of 77.6%. Multivariate analysis showed that the most relevant collection of biomarkers for prediction of stage of hepatic fibrosis is: CA 19-9, age, alpha-2- macroglobulin, total bilirubin, platelet count & albumin. We developed a new score, named the "Egy-Score", using a regression equation composed of this panel of biomarkers. Egy-Score could differentiate no or early fibrosis (stage F0-F2 METAVIR) from severe fibrosis or cirrhosis (stage F3-F4 METAVIR) with 83.7% accuracy. CONCLUSIONS Non-invasive assessment of hepatic fibrosis could be done using the Egy-Score. Egy-Score could differentiate no or early fibrosis (stage F0-F2 METAVIR) from severe fibrosis or cirrhosis (stage F3 - F4 METAVIR) with 83.7% accuracy.
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Affiliation(s)
- Mohamed A. Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
- Corresponding author: Mohamed A. Alboraie, Department of Internal Medicine, Al-Azhar University, 11651 Cairo, Egypt. Tel: +20-1222717078, Fax: +20-2225104146, E-mail:
| | - Mahmoud E. Afifi
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Helmy A. Shalaby
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | | | | | | | - Amany R. Abo El-Seoud
- Department of Community Medicine and Public Health, Zagazig University, Zagazig, Egypt
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Yoo EJ, Kim BK, Kim SU, Park JY, Kim DY, Ahn SH, Han KH, Chon CY, Kim HS. Normal enhanced liver fibrosis (ELF) values in apparently healthy subjects undergoing a health check-up and in living liver donors in South Korea. Liver Int 2013; 33:706-13. [PMID: 23490160 DOI: 10.1111/liv.12136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/04/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND The enhanced liver fibrosis (ELF) value is a non-invasive serum marker used for assessing liver fibrosis in chronic liver disease. To use the ELF value for the purpose of screening the general population and selecting subpopulations at high risk, it is important to know the normal range of ELF values as a prerequisite. AIMS We aimed to define the normal range of ELF values by recruiting apparently healthy subjects and investigating factors influencing ELF values in subjects with minimal fibrotic burden. METHODS ELF values were determined in a cohort of healthy subjects who underwent a health check-up and in healthy living liver donors who were screened for transplantation. None of subjects suffered from chronic heart disease, diabetes mellitus, metabolic syndrome, hepatitis B, hepatitis C, or human immunodeficiency virus infection, systemic autoimmune disease or liver dysfunction. RESULTS Among 183 subjects analyzed, the normal ELF 5th through 95th percentile range was 5.95-8.73. Body mass index (P = 0.014) and male gender (P = 0.015) showed significant positive correlations with ELF value, whereas age did not. In multivariate linear regression analysis, platelet count was identified as the only independent factor influencing the ELF value (β=-0.006, P = 0.016). When considering the difference in ELF values between genders, the normal range of men was defined to be 6.72-8.93, this was slightly higher than that of women, 5.69-8.67. CONCLUSIONS We identified the normal range of ELF values and found that it can be significantly influenced by platelet count even in the healthy population.
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Affiliation(s)
- Eun Jin Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Bhogal H, Sterling RK. Staging of liver disease: which option is right for my patient? Infect Dis Clin North Am 2013; 26:849-61. [PMID: 23083819 DOI: 10.1016/j.idc.2012.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
It is important to assess the stage of liver fibrosis in chronic hepatitis C to guide treatment decisions. Liver biopsy has limitations in staging fibrosis. Several blood tests, algorithms, and imaging tests have been studied as noninvasive markers to stage fibrosis in hepatitis C. In patients without suspicion for cirrhosis, 2 noninvasive methods can be used to predict presence of absence of significant liver fibrosis; however, liver biopsy remains the gold standard. It is imperative not to miss the diagnosis of cirrhosis, because this has further implications for screening of hepatocellular carcinoma and varices.
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Affiliation(s)
- Harjit Bhogal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
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Abignano G, Cuomo G, Buch MH, Rosenberg WM, Valentini G, Emery P, Del Galdo F. The enhanced liver fibrosis test: a clinical grade, validated serum test, biomarker of overall fibrosis in systemic sclerosis. Ann Rheum Dis 2013; 73:420-7. [DOI: 10.1136/annrheumdis-2012-202843] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gümüşay O, Ozenirler S, Atak A, Sönmez C, Ozkan S, Tuncel AF, Yılmaz G, Akyol G. Diagnostic potential of serum direct markers and non-invasive fibrosis models in patients with chronic hepatitis B. Hepatol Res 2013; 43:228-37. [PMID: 22734888 DOI: 10.1111/j.1872-034x.2012.01057.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM Liver biopsy is recommended in the majority of patients with chronic viral hepatitis for fibrosis evaluation. Because of the disadvantages of liver biopsy, many studies related to non-invasive biomarkers and scores have been performed. In this study, we aimed to assess the diagnostic value of serum direct markers and non-invasive fibrosis models to predict liver fibrosis in the treatment-naive chronic hepatitis B (CHB) patients and to compare their diagnostic performance. METHODS This study included 58 patients with a diagnosis of CHB virus infection and 30 healthy controls. Hyaluronic acid, tissue inhibitor of matrix metalloproteinase 1 and amino-terminal propeptide of type III procollagen were measured by enzyme-linked immunosorbent assay; and the Original European Liver Fibrosis panel, the Enhanced Liver Fibrosis (ELF) panel, PP score, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 indexes were calculated using the formulas taken from previous publications. Fibrosis stage was determined using Ishak's scoring system. RESULTS The fibrosis stages identified upon liver biopsy was F0 in 12 patients (20.7%), F1-2 in 36 (62.1%) and F3-5 in 10 (17.2%). The diagnostic value of all the non-invasive indices was low to detect mild fibrosis. We demonstrated that the diagnostic accuracy of HA is the best for predicting fibrosis of F3 or more (area under the receiver-operator curve, 0.902). In our study, the results from a combination of tests showed that ELF and APRI had the highest diagnostic value sensitivity of 90%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96.4% for detection of fibrosis of F3 or more. CONCLUSION In CHB patients, combination of ELF and APRI has a better diagnostic value in predicting fibrosis of F3 or more.
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Affiliation(s)
- Ozge Gümüşay
- Departments of Internal Medicine Gastroenterology Immunology Public Health Biochemistry Pathology, Gazi University Faculty of Medicine, Ankara, Turkey
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Leeming DJ, Byrjalsen I, Jiménez W, Christiansen C, Karsdal MA. Protein fingerprinting of the extracellular matrix remodelling in a rat model of liver fibrosis--a serological evaluation. Liver Int 2013; 33:439-47. [PMID: 23279004 DOI: 10.1111/liv.12044] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 09/13/2012] [Accepted: 10/27/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIM We investigated nine novel biomarkers of extracellular matrix (ECM) remodelling in a rat model of liver fibrosis. METHODS Liver fibrosis was induced in 52 male Wistar rats by inhalation of carbon tetrachloride and the level of hepatic fibrosis was assessed by Sirius red staining compared with controls. The novel serum biochemical markers assessed in the model were type I-(C1M), type III-(C3M), type IV-(C4M) and type VI-(C6M) collagen, citrullinated vimentin (VICM) and biglycan (BGM) all protein fragments generated by matrix metalloproteinases; and formation markers of type III-(P3NP), type VI (P4NP 7S) and type V (P5CP) collagen; hepatic mRNA type I collagen alpha-1 chain levels, serum potassium, sodium, osmolarity, alanine aminotransferase, lactate dehydrogenase, albumin and creatinine. RESULTS Stratification of the CCl(4) -treated rats according to total hepatic collagen showed that the degradation markers were significantly elevated in mild to severe fibrosis except for C6M which was also elevated in early fibrosis (P < 0.05). The highest Z-scores in early and moderate fibrosis were provided by P4NP 7S and alanine aminotransferase. All nine markers of ECM remodelling were highly related to the extent of liver fibrosis induced by CCl(4) . The novel collagen formation marker, P4NP 7S, was reliable for the detection of early fibrosis, while the combination of the two markers, C6M and P5CP provided the best correlation with hepatic fibrosis in all fibrosis levels. CONCLUSION As the markers can be used for translational science, these markers may provide valuable information for the evaluation of liver fibrosis in clinical settings.
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Affiliation(s)
- Diana J Leeming
- Nordic Bioscience, Fibrosis Biology and Biomarkers, Herlev, Denmark.
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Wahl K, Rosenberg W, Vaske B, Manns MP, Schulze-Osthoff K, Bahr MJ, Bantel H. Biopsy-controlled liver fibrosis staging using the enhanced liver fibrosis (ELF) score compared to transient elastography. PLoS One 2012; 7:e51906. [PMID: 23284811 PMCID: PMC3526479 DOI: 10.1371/journal.pone.0051906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 11/07/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Chronic liver diseases are characterized by inflammatory and fibrotic liver injuries that often result in liver cirrhosis with its associated complications such as portal hypertension and hepatocellular carcinoma. Liver biopsy still represents the reference standard for fibrosis staging, although transient elastography is increasingly used for non-invasive monitoring of fibrosis progression. However, this method is not generally available and is associated with technical limitations emphasizing the need for serological biomarkers staging of liver fibrosis. The enhanced liver fibrosis (ELF) score was shown to accurately predict significant liver fibrosis in different liver diseases, although extracellular matrix components detected by this score may not only mirror the extent of liver fibrosis but also inflammatory processes. METHODS In this prospective biopsy-controlled study we evaluated the utility of the ELF score in comparison to transient elastography to predict different stages of fibrosis in 102 patients with chronic liver diseases. RESULTS Both techniques revealed similar area under receiver operating characteristic curve values for prediction of advanced fibrosis stages. Compared to transient elastography, the ELF score showed a broader overlap between low and moderate fibrosis stages and a stronger correlation with inflammatory liver injury. CONCLUSIONS Both the ELF score as well as transient elastography allowed for high quality fibrosis staging. However, the ELF score was less discriminative in low and moderate fibrosis stages and appeared more strongly influenced by inflammatory liver injury. This should be considered when making clinical interpretations on the basis of ELF score values.
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Affiliation(s)
- Kristin Wahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - William Rosenberg
- Centre for Hepatology, University College London Institute of Liver and Digestive Health, Division of Medicine, University College London, London, United Kingdom
| | - Bernhard Vaske
- Institute of Biometry, Hannover Medical School, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | | | - Heike Bantel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- * E-mail:
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Bräu N. Evaluation of the hepatitis C virus-infected patient: the initial encounter. Clin Infect Dis 2012; 56:853-60. [PMID: 23243172 DOI: 10.1093/cid/cis957] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Deaths from hepatitis C virus (HCV)-related disease are increasing, now exceeding those from human immunodeficiency virus. Up to 7 million Americans (2.3%) may be infected with HCV, and more than half are undiagnosed. Proposed expansion of hepatitis C screening to include all persons born between 1945 and 1965 will lead to many new diagnoses, and infectious diseases physicians have a unique opportunity to be part of managing these patients. Apart from a liver-focused history and examination, the initial evaluation includes determination of the liver function via serum tests and assessment of liver fibrosis and necroinflammation through biopsy or noninvasive means. Patients with cirrhosis require screening for esophageal varices and for liver cancer. Nonimmune patients need vaccinations against hepatitis A and B, and alcohol abstinence is critical. Initial counseling on therapy emphasizes viral cure rates of currently 70%-80% as well as expected side effects. New treatments with fewer side effects and potentially higher cure rates are currently in development.
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Affiliation(s)
- Norbert Bräu
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, USA.
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An update on the management of hepatitis C: consensus guidelines from the Canadian Association for the Study of the Liver. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:359-75. [PMID: 22720279 DOI: 10.1155/2012/947676] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last consensus conference on the management of chronic hepatitis C, major advances have warranted a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed, and several single nucleotide polymorphisms associated with an increased probability of spontaneous and treatment-induced viral clearance have been identified. In light of this new evidence, a consensus development conference was held in November 2011; the present document highlights the results of the presentations and discussions surrounding these issues. It reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved protease inhibitors (boceprevir and telaprevir), including those who have previously failed pegylated interferon and ribavirin therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.
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ARFI, FibroScan, ELF, and their combinations in the assessment of liver fibrosis: a prospective study. J Hepatol 2012; 57:281-7. [PMID: 22521355 DOI: 10.1016/j.jhep.2012.03.016] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 03/01/2012] [Accepted: 03/12/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Our aim was to evaluate a serologic marker (ELF) and two ultrasound-based methods (FibroScan and ARFI), as well as their combinations, in the assessment of liver fibrosis. METHODS One-hundred and forty-six patients (87 liver transplant recipients, 59 non-transplant patients) who underwent liver biopsy were prospectively included. We evaluated the diagnostic accuracy of FibroScan, ARFI, ELF and the combination of ELF with either ARFI or FibroScan. After analyzing in separate transplant and non-transplant patients, the whole cohort was divided into a training set and a validation set. RESULTS ARFI imaging was successfully performed across the whole cohort, while FibroScan failed in 16 (11%) patients. The three methods showed similar AUROCs and best cut-off values in transplant and non-transplant patients. In the training set, differences between the AUROCs of ARFI, FibroScan and ELF to diagnose F⩾2 (0.879, 0.861, and 0.764, respectively) and cirrhosis (0.936, 0.918, and 0.841) were not statistically significant, although both ultrasound-based methods showed higher accuracy than ELF. The combination of ELF with ARFI or FibroScan increased the negative and positive predictive values of single tests for the diagnosis of F ≥ 2 and cirrhosis. Similar results were obtained when the methods were tested in the validation set. CONCLUSIONS ARFI is as effective as either FibroScan or ELF in the non-invasive assessment of liver fibrosis, and its inclusion in an ultrasound device could facilitate its incorporation into routine clinical practice. The combination of ARFI or FibroScan with ELF may help better identify patients with or without significant fibrosis or cirrhosis.
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Kim BK, Kim HS, Park JY, Kim DY, Ahn SH, Chon CY, Park YN, Han KH, Kim SU. Prospective validation of ELF test in comparison with Fibroscan and FibroTest to predict liver fibrosis in Asian subjects with chronic hepatitis B. PLoS One 2012; 7:e41964. [PMID: 22848675 PMCID: PMC3407050 DOI: 10.1371/journal.pone.0041964] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 06/27/2012] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIMS Liver stiffness measurement (LSM) and FibroTest (FT) are frequently used as non-invasive alternatives for fibrosis staging to liver biopsy. However, to date, diagnostic performances of Enhanced Liver Fibrosis (ELF) test, which consists of hyaluronic acid, aminoterminal propeptide of procollagen type-III, and tissue inhibitor of matrix metalloproteinases-1, have not been compared to those of LSM and FT in Asian chronic hepatitis B (CHB) patients. METHODS Between June 2010 and November 2011, we prospectively enrolled 170 CHB patients who underwent liver biopsies along with LSM, FT, and ELF. The Batts system was used to assess fibrosis stages. RESULTS Areas under receiver operating characteristic curves (AUROCs) to predict significant fibrosis (F≥2), advanced fibrosis (F≥3), and cirrhosis (F = 4) were 0.901, 0.860, and 0.862 for ELF, respectively; 0.937, 0.956, and 0.963 for LSM; and 0.896, 0.921, and 0.881 for FT. AUROCs to predict F≥2 were similar between each other, whereas LSM and FT had better AUROCs than ELF for predicting F≥3 (both p<0.05), and LSM predicted F4 more accurately than ELF (p<0.05). Optimized cutoffs of ELF to maximize sum of sensitivity and specificity were 8.5, 9.4, and 10.1 for F≥2, F≥3, and F = 4, respectively. Using suggested ELF, LSM and FT cutoffs to diagnose F1, F2, F3, and F4, 91 (53.5%), 117 (68.8%), and 110 (64.7%) patients, respectively, were correctly classified according to histological results. CONCLUSIONS ELF demonstrated considerable diagnostic value in fibrosis staging in Asian CHB patients, especially in predicting F≥2. However, LSM consistently provided better performance for predicting F≥3 and F4.
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Affiliation(s)
- Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyon Suk Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Chae Yoon Chon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nyun Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Liver Cirrhosis Clinical Research Center, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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Gangadharan B, Bapat M, Rossa J, Antrobus R, Chittenden D, Kampa B, Barnes E, Klenerman P, Dwek RA, Zitzmann N. Discovery of novel biomarker candidates for liver fibrosis in hepatitis C patients: a preliminary study. PLoS One 2012; 7:e39603. [PMID: 22761838 PMCID: PMC3383672 DOI: 10.1371/journal.pone.0039603] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/22/2012] [Indexed: 01/06/2023] Open
Abstract
Background Liver biopsy is the reference standard for assessing liver fibrosis and no reliable non-invasive diagnostic approach is available to discriminate between the intermediate stages of fibrosis. Therefore suitable serological biomarkers of liver fibrosis are urgently needed. We used proteomics to identify novel fibrosis biomarkers in hepatitis C patients with different degrees of liver fibrosis. Methodology/Principal Findings Proteins in plasma samples from healthy control individuals and patients with hepatitis C virus (HCV) induced cirrhosis were analysed using a proteomics technique: two dimensional gel electrophoresis (2-DE). This technique separated the proteins in plasma samples of control and cirrhotic patients and by visualizing the separated proteins we were able to identify proteins which were increasing or decreasing in hepatic cirrhosis. Identified markers were validated across all Ishak fibrosis stages and compared to the markers used in FibroTest, Enhanced Liver Fibrosis (ELF) test, Hepascore and FIBROSpect by Western blotting. Forty four candidate biomarkers for hepatic fibrosis were identified of which 20 were novel biomarkers of liver fibrosis. Western blot validation of all candidate markers using plasma samples from patients across all Ishak fibrosis scores showed that the markers which changed with increasing fibrosis most consistently included lipid transfer inhibitor protein, complement C3d, corticosteroid-binding globulin, apolipoprotein J and apolipoprotein L1. These five novel fibrosis markers which are secreted in blood showed a promising consistent change with increasing fibrosis stage when compared to the markers used for the FibroTest, ELF test, Hepascore and FIBROSpect. These markers will be further validated using a large clinical cohort. Conclusions/Significance This study identifies 20 novel fibrosis biomarker candidates. The proteins identified may help to assess hepatic fibrosis and eliminate the need for invasive liver biopsies.
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Affiliation(s)
- Bevin Gangadharan
- Oxford Antiviral Drug Discovery Unit, Department of Biochemistry, Oxford Glycobiology Institute, University of Oxford, Oxford, United Kingdom.
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Biomarkers in liver disease: emerging methods and potential applications. Int J Hepatol 2012; 2012:437508. [PMID: 23209913 PMCID: PMC3502848 DOI: 10.1155/2012/437508] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 12/11/2022] Open
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Valva P, Casciato P, Diaz Carrasco JM, Gadano A, Galdame O, Galoppo MC, Mullen E, De Matteo E, Preciado MV. The role of serum biomarkers in predicting fibrosis progression in pediatric and adult hepatitis C virus chronic infection. PLoS One 2011; 6:e23218. [PMID: 21858035 PMCID: PMC3157356 DOI: 10.1371/journal.pone.0023218] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 07/08/2011] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Liver biopsy represents the gold standard for damage evaluation, but noninvasive serum markers that mirror liver fibrosis progression are actual goals both in adults and especially in children. The aim was to determine specific serum markers that correlate with liver fibrosis progression during chronic HCV infection. Methods Liver biopsies and concomitant serum samples from 22 pediatric and 22 adult HCV patients were analyzed. Histological parameters were evaluated. On serum TGF-ß1, tissue inhibitor of matrix metalloprotein inhibitor-1 (TIMP-1), hyaluronic acid (HA) and aminoterminal peptide of procollagen type III (PIIINP) were tested. Results Significant fibrosis (F≥2) and advanced fibrosis (F≥3) represented 64% and 20%, respectively in children; while 54% F≥2 and 23% F≥3 in adults. Hyaluronic acid (p = 0.011) and PIIINP (p = 0.016) were related to worse fibrosis stages only in adults, along with TIMP-1 (p = 0.039) just in children; but TGF-ß1 was associated with mild fibrosis (p = 0.022) in adults. The AUROC of TIMP-1 in children to discriminate advanced fibrosis was 0.800 (95%IC 0.598–0.932). In adults, the best AUROCs were that of HA, PIIINP and TGF-ß1 [0.929 (IC95% 0.736–0.994), 0.894 (IC95% 0.689–0.984) and 0.835 (IC95% 0.617–0.957)], respectively. In children, according to the cut off (165.7 ng/mL) value for TIMP-1, biopsies could have been avoided in 72% (18/25). Considering the cut off for HA (109.7 ng/mL), PIIINP (9.1 µg/L), and TGF-ß1 (10,848.3 pg/mL), biopsies could have been avoided in 87% (19/22) of adult patients by using HA and 73% (16/22) using PIIINP or TGF-ß1. Conclusions In adults given the diagnostic accuracy of HA, PIIINP, TGF-ß1, their combination may provide a potential useful tool to assess liver fibrosis. This first pediatric study suggests that TIMP-1 is clinically useful for predicting liver fibrosis in HCV patients.
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Affiliation(s)
- Pamela Valva
- Laboratory of Molecular Biology, Pathology Division, Ricardo Gutiérrez Children's Hospital, Buenos Aires, Argentina.
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EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol 2011; 55:245-64. [PMID: 21371579 DOI: 10.1016/j.jhep.2011.02.023] [Citation(s) in RCA: 968] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 01/19/2023]
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J.S. Cross T, Jothimani D, Heneghan MA, Harrison PM. Non-invasive assessment of fibrosis in liver grafts due to hepatitis C virus recurrence. Clin Transplant 2011; 25:345-51. [DOI: 10.1111/j.1399-0012.2011.01396.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Friedrich-Rust M, Rosenberg W, Parkes J, Herrmann E, Zeuzem S, Sarrazin C. Comparison of ELF, FibroTest and FibroScan for the non-invasive assessment of liver fibrosis. BMC Gastroenterol 2010; 10:103. [PMID: 20828377 PMCID: PMC2944336 DOI: 10.1186/1471-230x-10-103] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 09/09/2010] [Indexed: 02/07/2023] Open
Abstract
Background FibroTest (FT) is the most frequently used serum fibrosis marker and consists of an algorithm of five fibrosis markers (alfa2-macroglobulin, apolipoproteinA1, haptoglobin, GGT, bilirubin). The Enhanced Liver Fibrosis (ELF) test consists of an algorithm of three fibrosis markers (hyaluronic acid, amino-terminal propeptide-of-type-III-collagen, tissue-inhibitor of matrix-metaloproteinase-1). While a systematic review has shown comparable results for both individual markers, there has been no direct comparison of both markers. Methods In the present study, the ELF-test was analyzed retrospectively in patients with chronic liver disease, who received a liver biopsy, transient elastography (TE) and the FibroTest using histology as the reference method. Histology was classified according to METAVIR and the Ludwig's classification (F0-F4) for patients with chronic hepatitis C and B virus (HCV, HBV) infection and primary biliary cirrhosis (PBC), respectively. Results Seventy-four patients were analysed: 36 with HCV, 10 with HBV, and 28 with PBC. The accuracy (AUROC) for the diagnosis of significant fibrosis (F≥2) for ELF and FibroTest was 0.78 (95%CI:0.67-0.89) and 0.69 (95%-CI:0.57-0.82), respectively (difference not statistically significant, n.s.). The AUROC for the diagnosis of liver cirrhosis was 0.92 (95%CI:0.83-1,00), and 0.91 (95%CI:0.83-0.99), respectively (n.s.). For 66 patients with reliable TE measurements the AUROC for the diagnosis of significant fibrosis (cirrhosis) for TE, ELF and FT were 0.80 (0.94), 0.76 (0.92), and 0.67 (0.91), respectively (n.s.). Conclusion FibroTest and ELF can be performed with comparable diagnostic accuracy for the non-invasive staging of liver fibrosis. Serum tests are informative in a higher proportion of patients than transient elastography.
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Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine 1, JW Goethe-University Hospital, Frankfurt, Germany
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