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Sebastiani G, Halfon P, Castera L, Mangia A, Di Marco V, Pirisi M, Voiculescu M, Bourliere M, Alberti A. Comparison of three algorithms of non-invasive markers of fibrosis in chronic hepatitis C. Aliment Pharmacol Ther 2012; 35:92-104. [PMID: 22035045 DOI: 10.1111/j.1365-2036.2011.04897.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preliminary data suggest that performance of non-invasive markers for liver fibrosis in hepatitis C may improve when combined. Three algorithms based on the combination of Fibrotest, Forns' index and AST-to-platelet ratio (APRI) have been proposed: Sequential Algorithm for Fibrosis Evaluation (SAFE biopsy); Fibropaca algorithm; Leroy algorithm. AIM To compare three algorithms to diagnose significant fibrosis (≥ F2 by METAVIR) and cirrhosis (F4). METHODS A total of 1013 HCV monoinfected cases undergoing liver biopsy were consecutively enrolled in seven centres. Fibrotest, APRI and Forns' index were measured at the time of liver biopsy, considered the reference standard. RESULTS Overall, performance of combination algorithms was significantly higher than the single non-invasive methods (P < 0.0001). SAFE biopsy and Fibropaca algorithm saved a significantly higher number of liver biopsies than the single methods (P < 0.0001). For ≥ F2, Fibropaca algorithm saved more biopsies than SAFE biopsy (51.7% vs. 43.8%, P = 0.0003), but with lower accuracy (87.6% vs. 90.3%, P = 0.05). Regarding F4, the number of saved liver biopsies did not differ between SAFE biopsy and Fibropaca algorithm (79.1% vs. 76.2%, P = 0.12). However, SAFE biopsy showed a lower accuracy when compared with Fibropaca algorithm (91.2% vs. 94%, P = 0.02). As to Leroy algorithm, although it showed a good performance for ≥ F2 (93.5% accuracy), it saved less liver biopsies than SAFE biopsy and Fibropaca algorithm (29.2% vs. 43.8% and 51.7% respectively, P < 0.0001). CONCLUSIONS SAFE biopsy and the Fibropaca algorithm have excellent performance for liver fibrosis in hepatitis C, allowing a significant reduction in the need for liver biopsies. They can be useful in clinical practice and for large-scale screening.
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Affiliation(s)
- G Sebastiani
- VIMM-Venetian Institute of Molecular Medicine, Padova, Italy
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102
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Sebastiani G, Alberti A. How far is noninvasive assessment of liver fibrosis from replacing liver biopsy in hepatitis C? J Viral Hepat 2012; 19 Suppl 1:18-32. [PMID: 22233410 DOI: 10.1111/j.1365-2893.2011.01518.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic hepatitis C represents a major cause of progressive liver disease that can eventually evolve into cirrhosis and its end-stage complications. Formation and accumulation of fibrosis in the liver is the common pathway that leads to evolutive liver disease. Precise staging of liver fibrosis is essential for patient management in clinical practice because the presence of bridging fibrosis represents a strong indication for antiviral therapy, while cirrhosis requires a specific follow-up. Liver biopsy has always represented the standard of reference for assessment of hepatic fibrosis, but it has limitations: it is invasive, costly and prone to sampling errors. Recently, blood markers and instrumental methods have been proposed for the noninvasive assessment of liver fibrosis in hepatitis C. However, international guidelines do not recommend the widespread use of noninvasive methods for liver fibrosis in clinical practice. This is because of, in some cases, unsatisfactory accuracy and incomplete validation of others. Some studies suggest that the effectiveness of noninvasive methods for assessing liver fibrosis may increase when they are combined, and a number of sequential and synchronous algorithms have been proposed for this purpose, with the aim of reducing rather than substituting liver biopsies. This may represent a rational and reliable approach for implementing noninvasive assessment of liver fibrosis in clinical practice. It could allow more comprehensive first-line screening of liver fibrosis in hepatitis C than would be feasible with liver biopsy alone.
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Affiliation(s)
- G Sebastiani
- VIMM-Venetian Institute of Molecular Medicine, Padua, Italy
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103
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Markers of inflammation and fibrosis in alcoholic hepatitis and viral hepatitis C. Int J Hepatol 2012; 2012:231210. [PMID: 22530132 PMCID: PMC3296182 DOI: 10.1155/2012/231210] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/31/2011] [Accepted: 11/23/2011] [Indexed: 12/15/2022] Open
Abstract
High levels of profibrinogenic cytokine transforming factor beta (TGF-β), metalloprotease (MMP2), and tissue inhibitor of matrix metalloprotease 1 (TIMP1) contribute to fibrogenesis in hepatitis C virus (HCV) infection and in alcohol-induced liver disease (ALD). The aim of our study was to correlate noninvasive serum markers in ALD and HCV patients with various degrees of inflammation and fibrosis in their biopsies. Methods. Serum cytokines levels in HCV-infected individuals in the presence or absence of ALD were measured. Student's-t-test with Bonferroni correction determined the significance between the groups. Results. Both tumor-necrosis-factor- (TNF)-α and TGF-β levels increased significantly with the severity of inflammation and fibrosis. TGF-β levels increased significantly in ALD patients versus the HCV patients. Proinflammatory cytokines' responses to viral and/or toxic injury differed with the severity of liver inflammation. A combination of these markers was useful in predicting and diagnosing the stages of inflammation and fibrosis in HCV and ALD. Conclusion. Therapeutic monitoring of TGF-β and metalloproteases provides important insights into fibrosis.
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104
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Poynard T, de Ledinghen V, Zarski JP, Stanciu C, Munteanu M, Vergniol J, France J, Trifan A, Moussalli J, Lebray P, Thabut D, Ratziu V. FibroTest and Fibroscan performances revisited in patients with chronic hepatitis C. Impact of the spectrum effect and the applicability rate. Clin Res Hepatol Gastroenterol 2011; 35:720-30. [PMID: 21852224 DOI: 10.1016/j.clinre.2011.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/06/2011] [Accepted: 07/11/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Two widely used biomarkers of fibrosis, FibroTest and liver stiffness measurement (LSM), have been mostly validated in patients with chronic hepatitis C (CHC) using the standard area under the ROC curve (sAUROC) which is not the most appropriate method due to the risk of fibrosis spectrum effect. Furthermore the performance of these biomarkers have not been assessed in "intention to diagnose" which takes into account the failures and non-reliable results. AIM The aim was to compare the accuracy of FibroTest and LSM for the diagnosis of fibrosis using sAUROC, the pairwise comparison of fibrosis stages by Obuchowski measure (wAUROC), and these AUROCs reassessed after taking into account the applicability rates. METHODS One thousand two hundred and eighty-nine patients with CHC and 604 healthy volunteers were analyzed. The performances of biomarkers assessed were compared in a patients-only group (P1: n=1289), in a population combining both patients and healthy volunteers (P2: n=1893) and in a simulated population (P3: n=1893) with the prevalence of stages observed in a reference population, to demonstrate the impact of spectrum effect. Applicability rates were estimated prospectively in 24,872 consecutive FibroTest and in 13,669 consecutive LSM examinations. RESULTS Using wAUROC, the conclusions of studies with reliable results in P1 were different than in those of P2 and in P3. There was a lower performance of FibroTest versus LSM in P1 (0.864 [0.855-0.873] vs. 0.883 [0.874-0.892]; P=0.002) which was not found in P2 (0.893 [0.887-0.900] vs. 0.894 [0.887-0.901]; P=0.86) and in P3 (0.899 [0.893-0.905] vs 0.902 [0.895-0.909]; P=0.60). Using the sAUROC, in P1, P2 and P3, there was no significant difference between FibroTest and LSM performance for advanced fibrosis and a lower performance of FibroTest versus LSM for cirrhosis. In intention to diagnose, using wAUROCs performances were higher for FibroTest vs. LSM in P1 (0.857 [0.848-0.866] vs. 0.814 [0.807-0.821]; P<0.0001) and P2 (0.885 [0.879-0.892] vs. 0.743 [0.737-0.749]; P<0.0001), without difference in P3 (0.891 [0.885-0.897] vs. 0.894 [0.887-0.901]; P=0.90). Using sAUROC, the significant differences in favor of FibroTest vs LSM persisted also for the diagnosis of advanced fibrosis, both in P1 and P2 (P<0.0001) and for the diagnosis of cirrhosis in P1 (P<0.001). CONCLUSION When the spectrum effects and applicability rates were taken into account, LSM had lower performance results than FibroTest for the diagnosis of fibrosis stages.
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105
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Sebastiani G, Castera L, Halfon P, Pol S, Mangia A, Di Marco V, Pirisi M, Voiculescu M, Bourliere M, Alberti A. The impact of liver disease aetiology and the stages of hepatic fibrosis on the performance of non-invasive fibrosis biomarkers: an international study of 2411 cases. Aliment Pharmacol Ther 2011; 34:1202-16. [PMID: 21981787 DOI: 10.1111/j.1365-2036.2011.04861.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Performance of non-invasive fibrosis biomarkers may be influenced by aetiology of chronic liver disease (CLD) and the stages of hepatic fibrosis, but large-scale studies are pending. AIM To investigate the effect of aetiogy and stages of hepatic fibrosis on the performance of fibrosis biomarkers. METHODS A total of 2411 patients with compensated CLD (HCV=75.1%, HBV=10.5%, NASH=7.9%, HIV/HCV=6.5%) were consecutively enrolled in 9 centres. APRI, Forns'index, Lok index, AST-to-ALT ratio, Fib-4, platelets and Fibrotest-Fibrosure were tested against liver biopsy, considered the gold standard. The effect of the stages of hepatic fibrosis to diagnose significant fibrosis and cirrhosis (≥F2 and F4 respectively) was investigated through difference between advanced and non-advanced fibrosis stages (DANA). Performance was expressed as observed area under the ROC curve (ObAUROC) and AUROC adjusted for DANA (AdjAUROC). RESULTS Performance of APRI and Fibrotest-Fibrosure was higher than other biomarkers. In all aetiologies, AdjAUROC was higher than ObAUROC. APRI showed its best performance in HCV monoinfected cases, with an AdjAUROC of 0.77 and 0.83 for ≥F2 and F4 respectively. In HBV and non-alcoholic steatohepatitis (NASH) patients, its performance was poor (AdjAUROC <0.70). Performance of Fibrotest-Fibrosure was good in all aetiologies for both ≥F2 and F4 (AdjAUROC >0.73), except for ≥F2 in NASH (AdjAUROC = 0.64). Performance of all biomarkers was reduced in HCV cases with normal ALT. CONCLUSIONS Aetiology is a major factor influencing the performance of liver fibrosis biomarkers. Even after correction for DANA, APRI and Fibrotest-Fibrosure exhibit the best performance. However, liver biopsy is not replaceable, especially to diagnose ≥F2 and in HCV carriers with normal ALT.
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Affiliation(s)
- G Sebastiani
- VIMM-Venetian Institute of Molecular Medicine, Padua, Italy
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106
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Pizano-Martínez O, Yañez-Sánchez I, Alatorre-Carranza P, Miranda-Díaz A, Ortiz-Lazareno PC, García-Iglesias T, Daneri-Navarro A, Mercado MVD, Fafutis-Morris M, Delgado-Rizo V. YKL-40 expression in CD14 + liver cells in acute and chronic injury. World J Gastroenterol 2011; 17:3830-5. [PMID: 21987626 PMCID: PMC3181445 DOI: 10.3748/wjg.v17.i33.3830] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To demonstrate that CD14+ cells are an important source of the growth factor YKL-40 in acute and chronic liver damage.
METHODS: Rats were inoculated with one dose of CCl4 to induce acute damage. Liver biopsies were obtained at 0, 6, 12, 24, 48 and 72 h. For chronic damage, CCl4 was administered three days per week for 6 or 8 wk. Tissue samples were collected, and cellular populations were isolated by liver digestion and purified by cell sorting. YKL-40 mRNA and protein expression were evaluated by real-time polymerase chain reaction and western blot.
RESULTS: Acute liver damage induced a rapid increase of YKL-40 mRNA beginning at 12 h. Expression peaked at 24 h, with a 26-fold increase over basal levels. By 72 h however, YKL-40 expression levels had nearly returned to control levels. On the other hand, chronic damage induced a sustained increase in YKL-40 expression, with 7- and 9-fold higher levels at 6 and 8 wk, respectively. The pattern of YKL-40 expression in different subpopulations showed that CD14+ cells, which include Kupffer cells, are a source of YKL-40 after acute damage at 72 h [0.09 relative expression units (REU)] as well as after chronic injury at 6 wk (0.11 REU). Hepatocytes, in turn, accounted for 0.06 and 0.01 REU after 72 h (acute) or 6 wk (chronic), respectively. The rest of the CD14- cells (including T lymphocytes, B lymphocytes, natural killer and natural killer T cells) yielded 0.07 and 0.15 REU at 72 h and 6 wk, respectively. YKL-40 protein expression in liver was detected at 72 h as well as 6 and 8 wk, with the highest expression relative to controls (11-fold; P≤ 0.05) seen at 6 wk. Macrophages were stimulated by lipopolysaccharide. We demonstrate that under these conditions, these cells showed maximum expression of YKL-40 at 12 h, with P < 0.05 compared with controls.
CONCLUSION: Hepatic CD14+ cells are an YKL-40 mRNA and protein source in acute and chronic liver injury, with expression patterns similar to growth factors implicated in inflammation-fibrogenesis.
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107
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El-Shabrawi MH, Isa M. Noninvasive Methods to Evaluate Liver Fibrosis in Chronic HCV Infection. HEPATITIS MONTHLY 2011; 11:758-759. [DOI: 10.5812/kowsar.1735143x.1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
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108
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Ladero JM. Noninvasive evaluation of liver fibrosis in patients with chronic hepatitis C. HEPATITIS MONTHLY 2011; 11:698-700. [PMID: 22235211 PMCID: PMC3234540 DOI: 10.5812/kowsar.1735143x.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/15/2011] [Accepted: 07/19/2011] [Indexed: 12/11/2022]
Affiliation(s)
- Jose M. Ladero
- Liver Unit, Gastroenterology Service, Hospital Clinico San Carlos, Department of Medicine, Complutense UniversityMadrid, Spain
- Corresponding author at: Jose M. Ladero, Liver Unit, Gastroenterology Service, Hospital Clinico San Carlos, Department of Medicine, Complutense University, Madrid, Spain. Tel.: +34-913303000, Fax: +34-9133505, E-mail:
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109
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El-Shabrawi MH, Isa M. Noninvasive methods to evaluate liver fibrosis in chronic HCV infection. HEPATITIS MONTHLY 2011; 11:758-9. [PMID: 22235222 PMCID: PMC3234539 DOI: 10.5812/kowsar.1735143x.711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 06/11/2011] [Accepted: 06/14/2011] [Indexed: 12/11/2022]
Affiliation(s)
- Mortada Hassan El-Shabrawi
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
- Corresponding author at: Mortada Hassan El-Shabrawi, Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt. Tel.: +20-123133705, Fax: +20-237619012, E-mail:
| | - Mona Isa
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
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110
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Uslusoy HS, Nak SG, Gülten M. Noninvasive predictors for liver fibrosis in patients with nonalcoholic steatohepatitis. World J Hepatol 2011; 3:219-27. [PMID: 21954411 PMCID: PMC3180608 DOI: 10.4254/wjh.v3.i8.219] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 06/06/2011] [Accepted: 07/18/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate certain anthropometric, clinical and laboratory features indicating liver fibrosis in nonalcoholic steatohepatitis and to establish the noninvasive markers for liver fibrosis. METHODS Eighty-one patients (40 male, 41 female) who were diagnosed with fatty liver by ultrasonographic examination and fulfilled the inclusion criteria participated in the study. Anamnesis, anthropometric, clinical and laboratory features of all cases were recorded and then liver biopsy was performed after obtaining patient consent. Steatosis, necroinflammation and liver fibrosis were examined according to age ≥ 45, gender, body mass index, central obesity, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) > 1, γ-glutamyltransferase (GGT)/ALT > 1, platelet count, insulin, c-peptide levels and the presence of hypertension, diabetes, hypertriglyceridemia and insulin resistance. RESULTS Eighty-one patients with non-alcoholic steatohepatitis (NASH) enrolled in the study. 69 of 81 patients were diagnosed with NASH, 11 were diagnosed with simple fatty liver and 1 was diagnosed with cirrhosis. AST/ALT > 1, GGT/ALT > 11, high serum ferritin and fasting insulin levels, the presence of diabetes, hypertension, hypertriglyceridemia and insulin resistance seemed to enhance the severity of steatosis, necroinflammation and fibrosis but these results were not statistically significant. CONCLUSION Liver steatosis and fibrosis can occur in individuals with normal weight. There was no significant concordance between severity of liver histology and the presence of predictors for liver fibrosis including metabolic risk factors.
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Affiliation(s)
- Hüseyin Saadettin Uslusoy
- Hüseyin Saadettin Uslusoy, Selim Giray Nak, Macit Gülten, Department of Gastrenterology, İzmit Seka State Hospital, Kocaeli 41000, Turkey
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111
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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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112
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Baranova A, Lal P, Birerdinc A, Younossi ZM. Non-invasive markers for hepatic fibrosis. BMC Gastroenterol 2011; 11:91. [PMID: 21849046 PMCID: PMC3176189 DOI: 10.1186/1471-230x-11-91] [Citation(s) in RCA: 204] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/17/2011] [Indexed: 01/18/2023] Open
Abstract
With great advancements in the therapeutic modalities used for the treatment of chronic liver diseases, the accurate assessment of liver fibrosis is a vital need for successful individualized management of disease activity in patients. The lack of accurate, reproducible and easily applied methods for fibrosis assessment has been the major limitation in both the clinical management and for research in liver diseases. However, the problem of the development of biomarkers capable of non-invasive staging of fibrosis in the liver is difficult due to the fact that the process of fibrogenesis is a component of the normal healing response to injury, invasion by pathogens, and many other etiologic factors. Current non-invasive methods range from serum biomarker assays to advanced imaging techniques such as transient elastography and magnetic resonance imaging (MRI). Among non-invasive methods that gain strongest clinical foothold are FibroScan elastometry and serum-based APRI and FibroTest. There are many other tests that are not yet widely validated, but are none the less, promising. The rate of adoption of non-invasive diagnostic tests for liver fibrosis differs from country to country, but remains limited. At the present time, use of non-invasive procedures could be recommended as pre-screening that may allow physicians to narrow down the patients' population before definitive testing of liver fibrosis by biopsy of the liver. This review provides a systematic overview of these techniques, as well as both direct and indirect biomarkers based approaches used to stage fibrosis and covers recent developments in this rapidly advancing area.
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Affiliation(s)
- Ancha Baranova
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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Anania C, Pacifico L, Ferraro F, Olivero E, Chiesa C. Aspartate transaminase to platelet ratio index (APRI) to assess liver fibrosis in patients with chronic liver disease. HEPATITIS MONTHLY 2011; 11:479-80. [PMID: 22087183 PMCID: PMC3212797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 04/06/2011] [Accepted: 04/09/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Caterina Anania
- Department of Paediatrics and Child Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Lucia Pacifico
- Department of Paediatrics and Child Neuropsychiatry, Sapienza University of Rome, Rome, Italy,Corresponding author at: Lucia Pacifico, Department of Paediatrics, Sapienza University of Rome, Viale Regina Elena, P.O. Box: 324 00161, Rome, Italy. Tel.: +39-0649979215, Fax: +39-0649979216, E-mail:
| | - Flavia Ferraro
- Department of Paediatrics and Child Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Eugenia Olivero
- Department of Paediatrics and Child Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Claudio Chiesa
- Institute of Translational Pharmacology, National Council Research, Rome, Italy
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Do serum CA 19-9 and CA 125 levels predict the severity of HCV-related liver fibrosis? EGYPTIAN LIVER JOURNAL 2011. [DOI: 10.1097/01.elx.0000397025.95176.ca] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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115
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Castera L. Invasive and non-invasive methods for the assessment of fibrosis and disease progression in chronic liver disease. Best Pract Res Clin Gastroenterol 2011; 25:291-303. [PMID: 21497746 DOI: 10.1016/j.bpg.2011.02.003] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 02/18/2011] [Indexed: 02/06/2023]
Abstract
Chronic liver diseases represent a major public health problem, accounting for significant morbidity and mortality worldwide. Their prognosis and management greatly depend on the amount and progression of liver fibrosis with the risk of developing cirrhosis. Liver biopsy, traditionally considered as the reference standard for staging of fibrosis, has been challenged over the past decade by the development of novel non invasive methodologies. These methods rely on two distinct but complementary approaches: i) a 'biological' approach based on the dosage of serum biomarkers of fibrosis; ii) a 'physical' approach based on the measurement of liver stiffness using transient elastography (TE). Non invasive methods have been initially studied and validated in chronic hepatitis C but are now increasingly used in other chronic liver diseases, resulting in a significant decrease in the need for liver biopsy. However, they will likely not completely abolish the need for liver biopsy and they should rather be employed as an integrated system with liver biopsy. This review is aimed at discussing the advantages and inconveniences of non invasive methods in comparison with liver biopsy for the management of patients with chronic liver diseases.
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Affiliation(s)
- Laurent Castera
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Denis Diderot Paris-7, 100 boulevard du General Leclerc, 92110 Clichy, France.
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Ahmad W, Ijaz B, Gull S, Asad S, Khaliq S, Jahan S, Sarwar MT, Kausar H, Sumrin A, Shahid I, Hassan S. A brief review on molecular, genetic and imaging techniques for HCV fibrosis evaluation. Virol J 2011; 8:53. [PMID: 21299910 PMCID: PMC3041775 DOI: 10.1186/1743-422x-8-53] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/08/2011] [Indexed: 02/08/2023] Open
Abstract
Background Chronic HCV is one of the major causes of morbidity and mortality in the present day world. The assessment of disease progression not only provides useful information for diagnosis and therapeutic supervision judgment but also for monitoring disease. Different invasive and non invasive methods are applied to diagnose the disease from initial to end stage (mild fibrosis to cirrhosis). Although, liver biopsy is still considered as gold standard to identify liver histological stages, an assessment of the disease development based on non-invasive clinical findings is also emerging and this may replace the need of biopsy in near future. This review gives brief insight on non-invasive methods currently available for predicting liver fibrosis in HCV with their current pros and cons to make easier for a clinician to choose better marker to assess liver fibrosis in HCV infected patients. Methods More than 200 studies regarding invasive and noninvasive markers available for HCV liver disease diagnosis were thoroughly reviewed. We examined year wise results of these markers based on their sensitivity, specificity, PPV, NPV and AUROCs. Results We found that in all non-invasive serum markers for HCV, FibroTest, Forn's Index, Fibrometer and HepaScore have high five-year predictive value but with low AUROCs (0.60~0.85) and are not comparable to liver biopsy (AUROC = 0.97). Even though from its beginning, Fibroscan is proved to be best with high AUROCs (> 0.90) in all studies, no single noninvasive marker is able to differentiate all fibrosis stages from end stage cirrhosis. Meanwhile, specific genetic markers may not only discriminate fibrotic and cirrhotic liver but also differentiate individual fibrosis stages. Conclusions There is a need of marker which accurately determines the stage based on simplest routine laboratory test. Genetic marker in combination of imaging technique may be the better non invasive diagnostic method in future.
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Affiliation(s)
- Waqar Ahmad
- Applied and Functional Genomics Laboratory, Centre of Excellence in Molecular Biology, University of the Punjab, Lahore, Pakistan
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Voumvouraki A, Koulentaki M, Notas G, Sfakianaki O, Kouroumalis E. Serum surrogate markers of liver fibrosis in primary biliary cirrhosis. Eur J Intern Med 2011; 22:77-83. [PMID: 21238899 DOI: 10.1016/j.ejim.2010.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 09/21/2010] [Accepted: 10/13/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hyaluronan, leptin, laminin and collagen IV have been used extensively for the assessment of liver fibrosis. The aim of this study was to assay these markers in the peripheral and hepatic vein blood of primary biliary cirrhosis (PBC) patients and to study their ability to discriminate early from advanced disease. METHODS Sera from 62 PBC patients were compared to 60 controls, 44 chronic Hepatitis C, 38 hepatocellular carcinoma and 34 viral cirrhosis patients. Serum from the hepatic vein of 15 cirrhotic PBC patients and 17 patients with viral cirrhosis was also assayed. RESULTS All disease groups had significantly increased levels of hyaluronan and collagen IV, compared to controls, while laminin was significantly increased only in viral cirrhosis. Hyaluronan levels were statistically different between early (54.5 ng/ml; 95%CI 27.3-426.9) and late PBC (154.5 ng/ml; 95%CI 55.3-764.4, p<0.05). The area under the curve (AUC) for the identification of late PBC was 0.74 for hyaluronan, 0.63 for leptin, 0.59 for laminin and 0.70 for collagen IV. Hyaluronan had high sensitivity and NPV in identifying late stages of PBC (96% and 90%, respectively). Short term UDCA had no effect on these markers. CONCLUSION No single measurement can differentiate between advanced and early fibrosis in PBC. However serum hyaluronan is a promising single serum marker for longitudinal studies in PBC.
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Affiliation(s)
- Argiro Voumvouraki
- University Hospital Department of Gastroenterology, University of Crete, Faculty of Medicine, Heraklion, 71100, Crete, Greece
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118
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Castera L. Non-invasive assessment of liver fibrosis in chronic hepatitis C. Hepatol Int 2011; 5:625-34. [PMID: 21484142 DOI: 10.1007/s12072-010-9240-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 12/16/2010] [Indexed: 02/06/2023]
Abstract
Quantification of hepatic fibrosis is of critical importance in chronic hepatitis C not only for prognosis, but also for antiviral treatment indication. Two end points are clinically relevant: detection of significant fibrosis (indication for antiviral treatment) and detection of cirrhosis (screening for eosphageal varices and hepatocellular carcinoma). Until recently, liver biopsy was considered the reference method for the evaluation of liver fibrosis. Limitations of liver biopsy (invasiveness, sampling error, and inter-observer variability) have led to the development of non-invasive methods. Currently available methods rely on two different approaches: a "biological" approach based on the dosage of serum fibrosis biomarkers; and a "physical" approach based on the measurement of liver stiffness, using transient elastography (TE). This review is aimed at discussing the advantages and limits of non-invasive methods and liver biopsy and the perspectives for their rational use in clinical practice in the management of patients with chronic hepatitis C.
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Affiliation(s)
- Laurent Castera
- Service d'Hépatologie, Hôpital Beaujon, AP-HP, Université Denis Diderot Paris-VII, Clichy, France,
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119
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A Besheer T, M El-Bendary M, R Zalata K, E Zaghalol H. Evaluation of Fibrosis Progression by
Noninvasive Biochemical Markers in
Egyptian Patients with Chronic Hepatitis B. Euroasian J Hepatogastroenterol 2011. [DOI: 10.5005/jp-journals-10018-1016] [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: 01/06/2023] Open
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120
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Sebastiani G, Pantopoulos K. Disorders associated with systemic or local iron overload: from pathophysiology to clinical practice. Metallomics 2011; 3:971-86. [DOI: 10.1039/c1mt00082a] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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121
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Cholongitas E, Tsochatzis E, Goulis J, Burroughs AK. Noninvasive tests for evaluation of fibrosis in HCV recurrence after liver transplantation: a systematic review. Transpl Int 2010; 23:861-70. [PMID: 20704691 DOI: 10.1111/j.1432-2277.2010.01142.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Noninvasive tests (NIT) for evaluation of hepatic fibrosis have not been evaluated extensively in liver transplantation. We systematically reviewed the literature regarding NIT after liver transplantation. We identified 14 studies evaluating NIT based on serum markers and/or liver imaging techniques: 10 studies assessed NIT in recipients with recurrent HCV infection for fibrosis and four studies evaluated predictors of progression of fibrosis in recurrent HCV. Transient Elastography (TE) had good discrimination for significant fibrosis (median AUROC: 0.88). Among the serum NIT, APRI had good performance (median AUROC: 0.75). TE performed better than serum (direct and indirect) NIT for significant fibrosis with median AUROC 0.88 (vs. 0.66, P < 0.001), median sensitivity 0.86 (vs. 0.56, P = 0.002), median NPV 0.90 (vs. 0.74, P = 0.05) and median PPV 0.80 (vs. 0.63, P = 0.02). TE compared to indirect serum NIT, had better performance, but was not superior to APRI score. Finally, direct, compared to indirect NIT, were not significantly different except for specificity: median: 0.83 vs. 0.69, respectively, P = 0.04. In conclusion, NIT could become an important tool in clinical management of liver transplant recipients, but whether they can improve clinical practice needs further evidence. Their optimal combination with liver biopsy and assessment of collagen content requires investigation.
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Affiliation(s)
- Evangelos Cholongitas
- The 4th Department of Internal Medicine, Medical School of Aristotle University, Greece. Royal Free Hospital, London, UK
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122
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Sebastiani G, Gkouvatsos K, Plebani M. Non-invasive assessment of liver fibrosis: it is time for laboratory medicine. Clin Chem Lab Med 2010; 49:13-32. [PMID: 20961196 DOI: 10.1515/cclm.2011.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic liver diseases (CLDs) represent a major cause of morbidity and mortality worldwide. In all etiologies of CLDs, staging of liver fibrosis is essential for both prognosis and management. Until a few years ago, liver biopsy was the only tool for the diagnosis of liver fibrosis in patients with CLDs. However, liver biopsy is an invasive and costly procedure. More recently, various serum biomarkers and laboratory tests have been proposed as surrogates of liver histology. Due to inadequate diagnostic accuracy or to lack of sufficient validation, guidelines still do not recommend them as a substitute for liver biopsy that is still considered the gold standard for the diagnosis of liver fibrosis. Notably, non-invasive serum biomarkers, when combined, may reduce by 50%-80% the number of liver biopsies needed for correctly classifying hepatic fibrosis. However, liver biopsy cannot be avoided completely, but should be used in those cases in which non-invasive methods show poor accuracy. In this view, serum biomarkers and liver biopsy represent a union between laboratory medicine and hepatology.
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Affiliation(s)
- Giada Sebastiani
- Department of Digestive Diseases, Hepatology and Clinical Nutrition, Dell'Angelo Hospital, Venice, Venetian Institute of Molecular Medicine (VIMM), Padova, Italy
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123
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Evaluation of liver fibrosis in patients with thalassemia: The important role of hyaluronic acid. Blood Cells Mol Dis 2010; 45:215-8. [DOI: 10.1016/j.bcmd.2010.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 02/06/2023]
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Poynard T, Afdhal NH. Perspectives on fibrosis progression in hepatitis C: an à la carte approach to risk factors and staging of fibrosis. Antivir Ther 2010; 15:281-91. [PMID: 20516548 DOI: 10.3851/imp1535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The morbidity and mortality of chronic hepatitis C is related to progressive fibrosis and the development of cirrhosis. The development of fibrosis in patients with HCV is highly influenced by immune status, host response to the virus and associated factors, such as, age, sex, alcohol intake, diabetes, obesity and coinfection with other viruses. The rate of fibrosis progression differs depending on several factors, including the stage of fibrosis and the time since infection. Routine assessment of fibrosis through biopsy every 3-5 years has poor patient acceptance and reliability, and might result in missed opportunities to improve or modify treatment priorities. Enhanced understanding of the pathophysiology of liver fibrosis in HCV infection has led to the development of a number of non-invasive assessment modalities. The ideal test would discriminate fibrosis in the categories none/early (stages 0/1), intermediate (stage 2) and advanced fibrosis/cirrhosis (stages 3/4) and be readily available, inexpensive and accurate. Biomarker tests utilize individual or combined serum markers to determine the degree of fibrosis. Other strategies combine biomarkers with clinical variables, such as patient age or utilize liver imaging or functional assessments. Incorporation of appropriately validated non-invasive assessments of liver fibrosis will likely improve the clinical care of patients with HCV infection.
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Affiliation(s)
- Thierry Poynard
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière AP-HP, University Paris 6, Paris, France
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125
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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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126
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Liu HB, Zhou JP, Zhang Y, Lv XH, Wang W. Prediction on liver fibrosis using different APRI thresholds when patient age is a categorical marker in patients with chronic hepatitis B. Clin Chim Acta 2010; 412:33-7. [PMID: 20828546 DOI: 10.1016/j.cca.2010.08.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 08/21/2010] [Accepted: 08/23/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patient age as a predictive variable plays an important role in some indices and models. It was hypothesized that patient age might be a categorical marker. METHODS We collected the data of 623 CHB patients with liver biopsies. Two-hundred fifty-two patients could provide the duration of HBsAg-positive. RESULTS The positive correlation between duration of HBsAg-positive and patient age was statistically significant (r = 0.487, P < 0.001). When the cutoff value of patient age was 33.5 y, the best accuracy for liver fibrosis could be obtained. If we could use APRI threshold value of 0.11 for patients with age ≤ 35 and 0.18 for those > 35 y, we could correctly identify 110 CHB patients with insignificant fibrosis which were free of liver biopsy. For all CHB patients based on the APRI threshold of 0.11, 75 patients could be safely predicted as insignificant fibrosis. CONCLUSIONS Many more CHB patients with insignificant fibrosis could be free of liver biopsy when we used different APRI threshold values based on patient age, especially in patients with > 35 y. The study indicated that more attention should be paid to the influence of patient age on fibrosis.
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Affiliation(s)
- Hong-Bo Liu
- School of Public Health, China Medical University, Shenyang, China.
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127
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Hepatobiliary function assessed by 99mTc-mebrofenin cholescintigraphy in the evaluation of fibrosis in chronic hepatitis: histopathological correlation. Nucl Med Commun 2010; 31:280-5. [PMID: 20087241 DOI: 10.1097/mnm.0b013e328334bff7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Although liver biopsy remains the gold standard in the staging of liver fibrosis in chronic hepatitis C virus (HCV) infection, several noninvasive methods are under evaluation for clinical use. The aim of this study was to evaluate the utility of hepatobiliary function through technetium-99m-N-(-3-bromo-2,4,6-trimethylacetanilide) iminodiacetic acid (Tc-mebrofenin) scintigraphy in evaluating liver fibrosis in patients with chronic HCV infection. METHODS We studied 62 patients with HCV (18 men, 44 women). The patients were allocated into three groups according to histopathological score: group 1: portal/periportal fibrosis (21 patients; eight men, 13 women); group 2: bridging fibrosis (23 patients; seven men, 16 women); and group 3: incomplete/complete cirrhosis (18 patients; three men, 15 women). As a control group, 20 healthy volunteers (six men and 14 women) were studied. Hepatocyte mebrofenin uptake rate, the time required for maximal hepatic activity (Tmax), and the time required for peak activity to decrease by 50% (T1/2max) were calculated using Tc-mebrofenin cholescintigraphy. Scintigraphic parameters were correlated with biochemical parameters and liver histopathology. RESULTS The uptake rates were significantly decreased in all groups with fibrosis compared with the controls (P<0.05). The correlation between the severity of fibrosis and Tc-mebrofenin uptake rate was strongly significant (r=-0.81, P<0.0001). Tmax and T1/2max were significantly prolonged in groups 2 and 3 compared with the controls. Histopathology score was correlated moderately with Tmax and T1/2max (r=0.61, P<0.0001 and r=0.52, P<0.0001, respectively). CONCLUSION The assessment of hepatobiliary function by Tc-mebrofenin scintigraphy may be a good choice for assessing the severity of liver fibrosis in patients with HCV.
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128
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Mangus RS, O'Connor MG, Tector AJ, Lim JD, Vianna RM. Use of the aspartate aminotransferase to platelet ratio index to follow liver fibrosis progression in infants with short gut. J Pediatr Surg 2010; 45:1266-73. [PMID: 20620330 DOI: 10.1016/j.jpedsurg.2010.02.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 02/23/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infants with parenteral nutrition dependence may develop liver dysfunction and progress to liver failure requiring transplantation. The aspartate aminotransferase-to-platelet ratio index (APRI) has good correlation with liver fibrosis progression in adults. This study applies APRI scoring to parenteral nutrition-dependant, short-gut infants to determine hepatic fibrosis progression. METHODS Laboratory values and biopsies were collected from initial intestinal resection (time 0) up to transplantation (end). Fibrosis scoring ranged from F0 (normal) to F4 (cirrhosis). Children were divided into 3 groups: (1) isolated intestine; and combined liver/intestine with gestational age (2) 34 weeks or greater and (3) 30 weeks or less. Liver function values over time, including calculated APRI, were analyzed as predictors of fibrosis. RESULTS Fifteen children who had 33 biopsies were included. Median APRI by fibrosis grade was F < or = 2: 1.88, F3: 3.23, and F4: 14.16 (P < .01). Median APRI at transplant by study group was (1) isolated intestine: 2.47, (2) liver/intestine 35 weeks or longer EGA: 14.16, and (3) liver/intestine 30 weeks or less EGA: 14.74 (P = .04). CONCLUSION Progression of APRI up to 60 days initially demonstrates similar values among study groups, but over time the score distinguishes those children with impending liver cirrhosis and differentiates fibrosis grade and study group.
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Affiliation(s)
- Richard S Mangus
- Department of Surgery, Transplant Section, Indiana University School of Medicine, Indianapolis, IN 46202-5250, USA.
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129
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Correia HST, Domingues ALC, Lopes EPA, Morais CNL, Sarteschi C, Moura IMF. [Serum globulin levels and intensity of hepatic fibrosis in patients with mansonic schistosomiasis]. ARQUIVOS DE GASTROENTEROLOGIA 2010; 46:194-8. [PMID: 19918685 DOI: 10.1590/s0004-28032009000300010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 01/07/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND A correlation between the levels of serum globulins and the hepatic fibrosis degree in chronic hepatitis was described, but reports in schistosomiasis mansoni have not been found. OBJECTIVE To evaluate the serum globulins and IgG levels, and periportal fibrosis intensity measured by ultrasound in patients with schistosomiasis mansoni. METHODS Between November, 2006 and February 2007, 41 patients which were eligible, filled them a questionnaire and had their levels of serum IgG measured by immunoturbidimetry and globulins indirectly measured by the Biuret method. The ultrasound was carried out by a single researcher, according to the Cairo and Niamey protocols. RESULTS The average age was 41 years old and 25 female patients (61%). Ten patients (24%) from 41 showed serum globulins levels raised and 21 (51%) presented elevated IgG levels. According to the Cairo classification, 21 patients showed grade I of fibrosis, 18 grade II and 2 grade III; and by the Niamey classification 8 showed standard C, 20 D, and 13 E. Those with grade II or III of fibrosis had higher IgG levels than the ones with grade I (P = 0.047), as well as those who showed standards D and E as compared to C (P = 0.011). There was no association between the globulins levels and the intensity of fibrosis. CONCLUSION In patients with schistosomiasis mansoni, an increase of the IgG serum levels was observed according to the progression from periportal fibrosis intensity, but the same was not founded with globulins levels.
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Affiliation(s)
- Henrique S T Correia
- Estudo desenvolvido no Ambulatório de Esquistossomose e no Laboratório Central do Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE
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Castéra L, Sebastiani G, Le Bail B, de Lédinghen V, Couzigou P, Alberti A. Prospective comparison of two algorithms combining non-invasive methods for staging liver fibrosis in chronic hepatitis C. J Hepatol 2010; 52:191-8. [PMID: 20006397 DOI: 10.1016/j.jhep.2009.11.008] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 08/06/2009] [Accepted: 09/01/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Non-invasive assessment of liver fibrosis is a challenging area. Several methods have been proposed in patients with chronic hepatitis C (CHC) but their performance may be improved when they are combined as suggested by recently proposed algorithms using either transient elastography (TE) and Fibrotest (FT) (Castera) or AST-to-Platelet Ratio Index (APRI) and FT (SAFE biopsy). The aim of this prospective study was to compare the performance of these two algorithms for diagnosing significant fibrosis and cirrhosis in 302 CHC patients. METHODS All patients underwent TE, FT and APRI the same day as liver biopsy, taken as reference standard. RESULTS Significant fibrosis (Metavir F>or=2) was present in 76% of patients and cirrhosis (F4) in 25%. TE failure was observed in eight cases (2.6%). For significant fibrosis, Castera algorithm saved 23% more liver biopsies (71.9% vs. 48.3%, respectively; p<0.0001) than SAFE biopsy but its accuracy was significantly lower (87.7% vs. 97.0%, respectively; p<0.0001). Regarding cirrhosis, accuracy of Castera algorithm was significantly higher than that of SAFE biopsy (95.7% vs. 88.7%, respectively; p<0.0001). The number of saved liver biopsies did not differ between the two algorithms (78.8% vs. 74.8%; p=NS). CONCLUSIONS Both algorithms are effective for non-invasive staging of liver fibrosis in chronic hepatitis C. Although the number of liver biopsies avoided does not differ between algorithms for diagnosing cirrhosis, it is significantly higher with Castera algorithm than SAFE biopsy for significant fibrosis.
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Affiliation(s)
- Laurent Castéra
- Service d'Hépato-Gastroentérologie, Hôpital Haut-Lévêque, Centre Hospitalier Universitaire (C.H.U.) de Bordeaux, Pessac, France.
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131
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Şirli R, Sporea I, Bota S, Popescu A, Cornianu M. A comparative study of non-invasive methods for fibrosis assessment in chronic HCV infection. HEPATITIS MONTHLY 2010; 10:88-94. [PMID: 22312379 PMCID: PMC3270362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 03/21/2010] [Accepted: 03/24/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS To compare several non-invasive methods of fibrosis assessment in chronic hepatitis C virus (HCV) infection (platelet count, the APRI score, the Forns score, the Lok score, FIB-4, Transient Elastography [TE]), versus percutaneous liver biopsy (LB). METHODS Our study included 150 patients with chronic HCV infection in which LB, liver stiffness measurement (LSM) by means of TE and biological tests needed for calculating the scores (according to the classic formulas) were performed in the same session. RESULTS The best test for predicting significant fibrosis (F = 2 Metavir) was LSM with AUROC-0.773, followed by APRI (AUROC-0.763), Forns (AUROC-0.744), platelet count (AUROC-0.732), Lok (AUROC-0.701) and FIB-4 (AUROC-0.669), but the differences were not statistically significant (P > 0.05). For excluding cirrhosis, all the tests had excellent NPV (>97%). The best test for predicting cirrhosis was LSM (AUROC-0.979), significantly better than platelet count (AUROC- 0.899, P = 0.022) and than FIB-4 (AUROC-0.839, P = 0.042), otherwise the differences were not statistically significant (P > 0.05). All of the non-invasive tests were statistically significantly correlated (P < 0.0001) to the severity of fibrosis: APRI r=0.570; Forns r=0.540; Lok r=0.4843; FIB-4 r=0.4171; platelet count r=-0.4842. CONCLUSIONS LSM by means of TE seems to be more sensitive than APRI, Forns, Lok and FIB-4 scores and than platelet count for the prediction of significant fibrosis, but the differences are not statistically significant. The APRI score and Forns scores correctly identified most (71%) of the patients having, or not having, significant fibrosis. LSM was the best method for predicting cirrhosis, but all the evaluated tests had excellent predictive value (AUROCs 0.839-0.979).
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Affiliation(s)
- Roxana Şirli
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timişoara, Romania,Corresponding author at: Roxana Şirli, M.D.Department of Gastroenterology, University of Medicine and Pharmacy, No. 14, Sirius St., Apt.5, Timişoara 300688,, Romania. Tel.: +40 723 537 039, Fax: +40 256 488 003, E-mail:
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timişoara, Romania
| | - Simona Bota
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timişoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timişoara, Romania
| | - Marioara Cornianu
- Department of Pathology, University of Medicine and Pharmacy, Timişoara, Romania
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Poynard T, Morra R, Ingiliz P, Imbert-Bismut F, Thabut D, Messous D, Munteanu M, Massard J, Benhamou Y, Ratziu V. Assessment of liver fibrosis: noninvasive means. Saudi J Gastroenterol 2009. [PMID: 19568532 DOI: 10.4103/1319-] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Liver biopsy, owing to its limitations and risks, is an imperfect gold standard for assessing the severity of the most frequent chronic liver diseases chronic hepatitis C (HCV), B (HBV) non alcoholic (NAFLD) and alcoholic (ALD) fatty liver diseases. This review summarizes the advantages and the limits of the available biomarkers of liver fibrosis. Among a total of 2,237 references, a total of 14 validated serum biomarkers have been identified between 1991 and 2008. Nine were not patented and five were patented. Two alternatives to liver biopsy were the most evaluated FibroTest and Fibroscan. For FibroTest, there was a total of 38 different populations including 7,985 subjects with both FibroTest and biopsy (4,600 HCV, 1,580 HBV, 267 NAFLD, 524 ALD, and 1014 mixed). For Fibroscan, there was a total of 11 published studies including 2,260 subjects (1,466 HCV, 95 cholestatic liver disease, and 699 mixed). For FibroTest, the mean diagnostic value for the diagnosis of advanced fibrosis assessed using standardized area under the ROC curves was 0.84 (95% confidence interval 0.83-0.86), without a significant difference between the causes of liver disease, hepatitis C, hepatitis B, and alcoholic or non alcoholic fatty liver disease. High-risk profiles of false negative/false positive of FibroTest, mainly Gilbert syndrome, hemolysis and acute inflammation, are present in 3% of the populations. In case of discordance between biopsy and FibroTest, half of the failures can be due to biopsy; the prognostic value of FibroTest is at least similar to that of biopsy in HCV, HBV and ALD. In conclusion this overview of evidence-based data suggests that biomarkers could be used as an alternative to liver biopsy for the first line assessment of fibrosis stage in the four most common chronic liver diseases, namely HCV, HBV, NAFLD and ALD. Neither biomarkers nor biopsy alone is sufficient for taking a definite decision in a given patient; all the clinical and biological data must be taken into account. There is no evidence based data justifying biopsy as a first line estimate of liver fibrosis. Health authorities in some countries have already approved validated biomarkers as the first line procedure for the staging of liver fibrosis.
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Affiliation(s)
- Thierry Poynard
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS ESA 8149 Paris, France.
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Razek AAKA, Abdalla A, Omran E, Fathy A, Zalata K. Diagnosis and quantification of hepatic fibrosis in children with diffusion weighted MR imaging. Eur J Radiol 2009; 78:129-34. [PMID: 19926420 DOI: 10.1016/j.ejrad.2009.10.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 10/08/2009] [Accepted: 10/09/2009] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the accuracy of diffusion weighted MR imaging in diagnosis and quantification of hepatic fibrosis in children with chronic hepatitis. MATERIALS AND METHODS Sixty-three consecutive children (40 boys, 23 girls, median age 9.3 years), with chronic hepatitis and thirty age matched volunteers underwent diffusion weighted MR imaging of the liver using a single shot echoplanar imaging with b-value=0, 250, and 500s/mm(2). Liver biopsy was obtained with calculation of METAVIR score. The ADC value of the liver was correlated with METAVIR score. Receiver operating characteristic curve was done for diagnosis and grading of hepatic fibrosis. RESULTS There was statistical difference in the mean ADC value between volunteers and patients with hepatic fibrosis (P=0.001) and in patients with different grades of METAVIR scores (P=0.002). There was correlation between the mean ADC value and METAVIR score (r=0.807, P=0.001). The cut off point to predict fibrosis (1.7×10(-3)mm(2)/s) revealed 83% accuracy, 85% sensitivity, 82% specificity, 83% PPV, and 85% NPV. The area under the curve was 0.91 for F1, 0.85 for F2, 0.86 for F3 and 0.90 for F4. CONCLUSION The apparent diffusion coefficient value is a promising quantitative parameter used for diagnosis and quantification of hepatic fibrosis in children with chronic hepatitis.
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Poynard T, Muntenau M, Morra R, Ngo Y, Imbert-Bismut F, Thabut D, Messous D, Massard J, Lebray P, Moussalli J, Benhamou Y, Ratziu V. Methodological aspects of the interpretation of non-invasive biomarkers of liver fibrosis: a 2008 update. ACTA ACUST UNITED AC 2009; 32:8-21. [PMID: 18973843 DOI: 10.1016/s0399-8320(08)73990-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review summarizes the methodological aspects of the interpretation of non-invasive biomarkers in liver fibrosis. A scoring system has been updated to better compare the quality of fibrosis biomarkers. Several methodological issues are related to the classical methodology using biopsy, as this is considered the gold standard. However, from evidence-based data, it appears that the methodology needs to change to prevent flawed conclusions among key opinion leaders as well as in obsolete guidelines. As waiting for the perfect biomarker for the diagnosis of advanced fibrosis to come along is probably a waste of time, in the meantime, methods can be improved. The main proposals for improving the methodology are, to take into account the spectrum bias, to assess accuracy between adjacent stages, to compare biomarkers in the same patient, to assess the cause of failure among discordant cases and to use specific statistical methods adapted for imperfect gold standards.
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Affiliation(s)
- T Poynard
- APHP Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris 6, CNRS ESA 8149 Paris, France.
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Abstract
Nucleoside or nucleotide analogs (NUCs) are a major step forward in the treatment of hepatitis B virus (HBV) infection. Apart from their proven antiviral efficacy, these drugs have proved able to significantly improve liver fibrosis as short-term treatment. Using different definitions of fibrosis regression, after 1 year of treatment, improvement in liver fibrosis was observed among HBe antigen (HBeAg)-positive naive patients: 35-61% with lamivudine; 41% with adefovir; 68% with telbivudine; 39% with entecavir; and 74% with tenofovir. Among HBeAg-negative patients, after 1 year of treatment, improvement in liver fibrosis was seen in: 36-46% with lamivudine; 48% with adefovir; 56% with telbivudine; 36% with entecavir; and 71% with tenofovir. Long-term treatment is often required with NUCs; the response continue to improve over time, reaching up to 63% of patients with lamivudine and 71% of patients with adefovir, although the development of antiviral drug resistance can blunt any histological improvement. Also, there is now growing evidence that non-invasive methods of fibrosis diagnosis, such as surrogate markers, are likely to become as important as liver biopsy for taking the initial decision to biopsy and for treatment, and in the follow-up of treated chronic HBV patients.
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Raoufy MR, Vahdani P, Alavian SM, Fekri S, Eftekhari P, Gharibzadeh S. A Novel Method for Diagnosing Cirrhosis in Patients with Chronic Hepatitis B: Artificial Neural Network Approach. J Med Syst 2009; 35:121-6. [DOI: 10.1007/s10916-009-9348-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 07/09/2009] [Indexed: 12/23/2022]
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Ingiliz P, Chhay KP, Munteanu M, Lebray P, Ngo Y, Roulot D, Benhamou Y, Thabut D, Ratziu V, Poynard T. Applicability and variability of liver stiffness measurements according to probe position. World J Gastroenterol 2009; 15:3398-404. [PMID: 19610141 PMCID: PMC2712901 DOI: 10.3748/wjg.15.3398] [Citation(s) in RCA: 17] [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: 01/09/2009] [Revised: 06/05/2009] [Accepted: 06/12/2009] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the liver stiffness measurement (LSM) applicability and variability with reference to three probe positions according to the region of liver biopsy. METHODS The applicability for LSM was defined as at least 10 valid measurements with a success rate greater than 60% and an interquartile range/median LSM < 30%. The LSM variability compared the inter-position concordance and the concordance with FibroTest. RESULTS Four hundred and forty two consecutive patients were included. The applicability of the anterior position (81%) was significantly higher than that of the reference (69%) and lower positions (68%), (both P = 0.0001). There was a significant difference (0.5 kPa, 95% CI 0.13-0.89; P < 0.0001) between mean LSM estimated at the reference position (9.3 kPa) vs the anterior position (8.8 kPa). Discordance between positions was associated with thoracic fold (P = 0.008). The discordance rate between the reference position result and FibroTest was higher when the 7.1 kPa cutoff was used to define advanced fibrosis instead of 8.8 kPa (33.6% vs 23.5%, P = 0.03). CONCLUSION The anterior position of the probe should be the first choice for LSM using Fibroscan, as it has a higher applicability without higher variability compared to the usual liver biopsy position.
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Sebastiani G, Halfon P, Castera L, Pol S, Thomas DL, Mangia A, Di Marco V, Pirisi M, Voiculescu M, Guido M, Bourliere M, Noventa F, Alberti A. SAFE biopsy: a validated method for large-scale staging of liver fibrosis in chronic hepatitis C. Hepatology 2009; 49:1821-7. [PMID: 19291784 DOI: 10.1002/hep.22859] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The staging of liver fibrosis is pivotal for defining the prognosis and indications for therapy in hepatitis C. Although liver biopsy remains the gold standard, several noninvasive methods are under evaluation for clinical use. The aim of this study was to validate the recently described sequential algorithm for fibrosis evaluation (SAFE) biopsy, which detects significant fibrosis (> or =F2 by METAVIR) and cirrhosis (F4) by combining the AST-to-platelet ratio index and Fibrotest-Fibrosure, thereby limiting liver biopsy to cases not adequately classifiable by noninvasive markers. Hepatitis C virus (HCV) patients (2035) were enrolled in nine locations in Europe and the United States. The diagnostic accuracy of SAFE biopsy versus histology, which is the gold standard, was investigated. The reduction in the need for liver biopsies achieved with SAFE biopsy was also assessed. SAFE biopsy identified significant fibrosis with 90.1% accuracy (area under the receiver operating characteristic curve = 0.89; 95% confidence interval, 0.87-0.90) and reduced by 46.5% the number of liver biopsies needed. SAFE biopsy had 92.5% accuracy (area under the receiver operating characteristic curve = 0.92; 95% confidence interval, 0.89-0.94) for the detection of cirrhosis, obviating 81.5% of liver biopsies. A third algorithm identified significant fibrosis and cirrhosis simultaneously with high accuracy and a 36% reduction in the need for liver biopsy. The patient's age and body mass index influenced the performance of SAFE biopsy, which was improved with adjusted Fibrotest-Fibrosure cutoffs. Two hundred two cases (9.9%) had discordant results for significant fibrosis with SAFE biopsy versus histology, whereas 153 cases (7.5%) were discordant for cirrhosis detection; 71 of the former cases and 56 of the latter cases had a Fibroscan measurement within 2 months of histological evaluation. Fibroscan confirmed SAFE biopsy findings in 83.1% and 75%, respectively. CONCLUSION SAFE biopsy is a rational and validated method for staging liver fibrosis in hepatitis C with a marked reduction in the need for liver biopsy. It is an attractive tool for large-scale screening of HCV carriers.
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Sebastiani G. Non-invasive assessment of liver fibrosis in chronic liver diseases: implementation in clinical practice and decisional algorithms. World J Gastroenterol 2009; 15:2190-203. [PMID: 19437558 PMCID: PMC2682233 DOI: 10.3748/wjg.15.2190] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 03/14/2009] [Accepted: 03/21/2009] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis B and C together with alcoholic and non-alcoholic fatty liver diseases represent the major causes of progressive liver disease that can eventually evolve into cirrhosis and its end-stage complications, including decompensation, bleeding and liver cancer. Formation and accumulation of fibrosis in the liver is the common pathway that leads to an evolutive liver disease. Precise definition of liver fibrosis stage is essential for management of the patient in clinical practice since the presence of bridging fibrosis represents a strong indication for antiviral therapy for chronic viral hepatitis, while cirrhosis requires a specific follow-up including screening for esophageal varices and hepatocellular carcinoma. Liver biopsy has always represented the standard of reference for assessment of hepatic fibrosis but it has some limitations being invasive, costly and prone to sampling errors. Recently, blood markers and instrumental methods have been proposed for the non-invasive assessment of liver fibrosis. However, there are still some doubts as to their implementation in clinical practice and a real consensus on how and when to use them is not still available. This is due to an unsatisfactory accuracy for some of them, and to an incomplete validation for others. Some studies suggest that performance of non-invasive methods for liver fibrosis assessment may increase when they are combined. Combination algorithms of non-invasive methods for assessing liver fibrosis may represent a rational and reliable approach to implement non-invasive assessment of liver fibrosis in clinical practice and to reduce rather than abolish liver biopsies.
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140
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Castera L. Transient elastography and other noninvasive tests to assess hepatic fibrosis in patients with viral hepatitis. J Viral Hepat 2009; 16:300-14. [PMID: 19254351 DOI: 10.1111/j.1365-2893.2009.01087.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The limitations of liver biopsy (invasive procedure, sampling errors, inter-observer variability and nondynamic fibrosis evaluation) have stimulated the search for noninvasive approaches for the assessment of liver fibrosis in patients with viral hepatitis. A variety of methods including the measurement of liver stiffness, using transient elastography, and serum markers, ranging from routine laboratory tests to more complex algorithms or indices combining the results of panels of markers, have been proposed. Among serum indices, Fibrotest has been the most extensively studied and validated. Transient elastography appears as a promising method but has been mostly validated in chronic hepatitis C with performance equivalent to that of serum markers for the diagnosis of significant fibrosis. The combination of both approaches as first-line assessment of liver fibrosis could avoid the performance of liver biopsy in the majority of patients with chronic hepatitis C, a strategy that deserves further evaluation in patients with hepatitis B or HIV-HCV coinfection. Transient elastography also appears to be an excellent tool for early detection of cirrhosis and may have prognostic value in this setting. Guidelines are now awaited for the use of noninvasive methods in clinical practice.
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Affiliation(s)
- Laurent Castera
- Department of Hepatology, Hôpital St André & Haut Lévêque, Bordeaux University Hospital, Bordeaux, France.
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141
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Uslusoy HS, Nak SG, Gülten M, Bıyıklı Z. Non-alcoholic steatohepatitis with normal aminotransferase values. World J Gastroenterol 2009; 15:1863-8. [PMID: 19370784 PMCID: PMC2670414 DOI: 10.3748/wjg.15.1863] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the aspects of liver histology in patients with non-alcoholic steatohepatitis (NASH) who had normal aminotransferase levels.
METHODS: Thirty-four patients diagnosed with liver steatosis by ultrasonographic examination participated in the study. We compared all non-alcoholic fatty liver disease and NASH cases, according to aminotransferase level, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio and presence of metabolic syndrome.
RESULTS: Sixteen of 25 patients with high aminotransferase levels were diagnosed with NASH and nine with simple fatty liver according to liver histology. Among the nine patients with normal aminotransferase levels, seven had NASH and two had simple fatty liver. The patients with normal and high liver enzyme levels had almost the same prevalence of NASH and metabolic syndrome. Liver histology did not reveal any difference according to aminotransferase levels and AST/ALT ratio.
CONCLUSION: Aminotransferase levels and AST/ALT ratio do not seem to be reliable predictors for NASH. Despite numerous non-invasive biomarkers, all patients with fatty liver should undergo liver biopsy.
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142
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Camps J, Marsillach J, Joven J. The paraoxonases: role in human diseases and methodological difficulties in measurement. Crit Rev Clin Lab Sci 2009; 46:83-106. [PMID: 19255916 DOI: 10.1080/10408360802610878] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Research into the paraoxonase (PON) gene family has flourished over the past few years. In the 1970s and 1980s, only PON1 was known, and the investigations were conducted, essentially, by toxicologists focusing on protection against organophosphate poisoning. Since then, two new members of the family, PON2 and PON3, have been identified, both being shown to play antioxidant and anti-inflammatory roles. Evidence exists indicating that the PON family is central to a wide variety of human illnesses such as cardiovascular disease, diabetes mellitus, metabolic syndrome, obesity, non-alcoholic steatohepatitis, and several mental disorders. However, research is hampered considerably by the methods currently available to measure the activity of these enzymes. In this review, we summarize the state of knowledge on PON biochemistry and function, the influence of genetic variations, and the involvement of PON in several diseases. The problems associated with PON measurement, such as sample acquisition, lack of reference methods, and variety of substrates, will be presented. Also, we cover some of the present lines of research and propose some others for future progress in this field.
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Affiliation(s)
- Jordi Camps
- Centre de Recerca Biomedica, Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain.
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Poynard T, Ngo Y, Marcellin P, Hadziyannis S, Ratziu V, Benhamou Y. Impact of adefovir dipivoxil on liver fibrosis and activity assessed with biochemical markers (FibroTest-ActiTest) in patients infected by hepatitis B virus. J Viral Hepat 2009; 16:203-13. [PMID: 19175871 DOI: 10.1111/j.1365-2893.2008.01065.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The aim was to assess the utility of FibroTest-ActiTest (FT-AT) as noninvasive markers of histological changes in patients with chronic hepatitis. Patients with chronic hepatitis B (HBeAg+ and HBeAg-) randomized in two trials of adefovir (ADV) vs placebo, with available paired liver biopsies and FT-AT at baseline and after 48 weeks of treatment were included. The predictive value of FT-AT was assessed using the area under the receiver operating characteristics curves (AUROCs) for the diagnosis of bridging fibrosis, cirrhosis and moderate-severe necroinflammatory activity. The impact of treatment with ADV vs placebo was assessed on liver injury according to baseline stage and virological response at 48 weeks. The analysis of 924 estimates for the diagnosis of bridging fibrosis, cirrhosis and moderate or severe necroinflammatory activity yielded FT-AT AUROCs: 0.76 +/- 0.02 (standardized 0.81 +/- 0.02), 0.81 +/- 0.02 and 0.80 +/- 0.01, respectively. Similar impacts of ADV on liver fibrosis and activity were observed both with paired biopsy (fibrosis stage from 1.6 to 1.4, activity grade from 2.5 to 1.3) and paired biomarkers (FT from 0.44 to 0.40, AT from 0.62 to 0.25) (P < 0.0001). FibroTest-ActiTest provides a quantitative estimate of liver fibrosis and necroinflammatory activity in patients with chronic hepatitis B and may be an alternative to reduce the need for liver biopsy.
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Affiliation(s)
- T Poynard
- Pitié-Salpêtrière, Université Paris, Paris, France.
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Alempijevic T, Krstic M, Jesic R, Jovanovic I, Milutinovic AS, Kovacevic N, Krstic S, Popovic D. Biochemical markers for non-invasive assessment of disease stage in patients with primary biliary cirrhosis. World J Gastroenterol 2009; 15:591-4. [PMID: 19195061 PMCID: PMC2653350 DOI: 10.3748/wjg.15.591] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate different biochemical markers and their ratios in the assessment of primary biliary cirrhosis (PBC) stages.
METHODS: This study included 112 patients with PBC who underwent a complete clinical investigation. We analyzed the correlation (Spearman's test) between ten biochemical markers and their ratios with different stages of PBC. The discriminative values were compared using areas under receiver operating characteristic (ROC) curves.
RESULTS: The mean age of patients included in the study was 53.88 ± 10.59 years, including 104 females and 8 males. We found a statistically significant correlation between PBC stage and Aspartate aminotransferase (AST), Alanine aminotransferase (ALT) to platelet ratio (APRI), ALT/platelet count, AST/ALT, ALT/AST and ALT/Cholesterol ratios, with the values of Spearman’s rho of 0.338, 0.476, 0.404, 0.356, 0.351 and 0.325, respectively. The best sensitivity and specificity was shown for AST/ALT, with an area under ROC of 0.660.
CONCLUSION: Biochemical markers and their ratios do correlate with different sensitivity to and specificity of PBC disease stage. The use of biochemical markers and their ratios in clinical evaluation of PBC patients may reduce, but not eliminate, the need for liver biopsy.
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145
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Nieminen U, Arkkila PET, Kärkkäinen P, Färkkilä MA. Effect of steatosis and inflammation on liver fibrosis in chronic hepatitis C. Liver Int 2009; 29:153-8. [PMID: 18482270 DOI: 10.1111/j.1478-3231.2008.01779.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIMS The role of liver biopsy has been questioned in the management of patients with hepatitis C viral (HCV) infection. The aims of this study were to determine the impact of clinical parameters and degree of inflammation and steatosis on liver fibrosis. PATIENTS/METHODS Clinical data and liver histology findings in 510 HCV patients were analysed. RESULTS Hepatitis C virus genotype 1 (GT-1) was found in 38%, GT-2 in 15% and GT-3 in 45% of patients. In liver biopsy specimens, inflammation activity was present in 68%, increased fibrosis in 19% and marked steatosis in 17% of patients. Independent clinical risk factors for the increased fibrosis were patients' age at biopsy, body mass index (BMI) and duration of HCV. Steatosis and inflammation activity were independent histological risk factors for fibrosis only in GT-1; in GT-3, only inflammation correlated independently with fibrosis. CONCLUSIONS Age at liver biopsy, BMI and duration of HCV were independent risk factors for increased fibrosis in HCV patients. Steatosis as a risk factor for fibrosis is evident in GT-1. When scoring liver biopsies of HCV patients, the degree of steatosis should be included in addition to fibrosis and inflammation activity.
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Affiliation(s)
- Urpo Nieminen
- Department of Medicine, Division of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland
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146
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Improved diagnostic accuracy of blood tests for severe fibrosis and cirrhosis in chronic hepatitis C. Eur J Gastroenterol Hepatol 2009; 21:28-38. [PMID: 19060630 DOI: 10.1097/meg.0b013e32830cebd7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Blood tests are usually designed to identify significant fibrosis. We evaluated their diagnostic accuracy, and how to increase it, for the clinically important targets of severe fibrosis and cirrhosis. METHODS The accuracy for severe fibrosis or cirrhosis of four blood tests was evaluated based on Metavir staging in 1056 patients with chronic hepatitis C recruited in five independent hospitals. RESULTS Using original scores, an original diagnostic target (significant fibrosis) and best diagnostic cutoff, the correct classification rates in severe fibrosis and cirrhosis stages were, respectively: FibroMeter: 90.1, 100%, Fibrotest: 78.2, 95.1%, Hepascore: 73.8, 94.9%, aspartate aminotransferase to platelet ratio index (APRI): 71.4, 88.0% (P<0.003, P=0.004, respectively, between tests). The corresponding area under the receiver operating characteristics were FibroMeter: 0.885, 0.907, Fibrotest: 0.837, 0.882, Hepascore: 0.834, 0.896, APRI: 0.822, 0.841 (P<0.003, respectively). Observed 100% negative predictive values for severe fibrosis and cirrhosis were, respectively, FibroMeter: 15.4, 47.5%, Fibrotest: 3.6, 31.9%, Hepascore: 0.3, 24.6%, APRI: 1.4, 5.3% of patients (P<0.003, respectively, between tests). By calculating a specific test for cirrhosis, including the FibroMeter markers, the correct classification (93.0%) was significantly higher for the cirrhosis diagnosis compared with the original FibroMeter (90.9%, P=0.005). This specific test provided a 100% positive predictive value for cirrhosis diagnosis versus 88% for original FibroMeter. CONCLUSION Using the most accurate original test, cirrhosis can be excluded in 47.5% of patients and is correctly diagnosed, as significant fibrosis, in 100% of patients. A specific test for cirrhosis provides a significant gain in diagnostic accuracy to 93% and in positive predictive value to 100% compared with the original test.
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147
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Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: comparison of transient elastography (FibroScan) with standard laboratory tests and non-invasive scores. J Hepatol 2009; 50:59-68. [PMID: 19013661 DOI: 10.1016/j.jhep.2008.08.018] [Citation(s) in RCA: 256] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 08/29/2008] [Accepted: 08/31/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS To assess prospectively the accuracy of transient elastography (TE, FibroScan) for the detection of cirrhosis and oesophageal varices (OV) in chronic hepatitis C (CHC), as compared with currently available non-invasive methods (AST/ALT ratio (AAR), APRI, prothrombin index (PI), platelet count (PC), FibroTest (FT) and Lok index). METHODS All tests were performed the day of liver biopsy (LB), taken as reference, in 298 consecutive CHC patients (cirrhosis: 70; Child-Pugh A: 70; OV: 25). RESULTS TE had the best diagnostic accuracy for detection of cirrhosis (AUROCs: TE 0.96 vs. FT 0.82, Lok and APRI 0.80, PC 0.79, PI 0.73, AAR 0.61, respectively; p < 0.0001). Overall, the percentage of saved LB was: TE (cut-off: 12.5 kPa) 90%, PC 82%, FT 79%, PI 77%, AAR 76%, APRI 70%, and Lok 45%, respectively. At a cut-off of 21.5 kPa, TE predicted the presence of OV with 76% sensitivity and 78% specificity and correctly classified 73% of patients vs. AAR 81%, Lok 77%, FT, PI 70%, PC 69%, and APRI 66%, respectively. CONCLUSIONS TE is currently the most accurate non-invasive method for early detection of cirrhosis in CHC (cut-off: 12.5 kPa), as compared with other available methods, but cannot replace endoscopy for OV screening.
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148
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Comparison of blood tests for liver fibrosis specific or not to NAFLD. J Hepatol 2009; 50:165-73. [PMID: 18977552 DOI: 10.1016/j.jhep.2008.07.035] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 06/01/2008] [Accepted: 07/02/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS To compare blood tests of liver fibrosis specific for NAFLD: the FibroMeter NAFLD and the NAFLD fibrosis score (NFSA) with a non-specific test, APRI. METHODS Two hundred and thirty-five NAFLD patients with liver Metavir staging and blood markers from two independent centres were randomly assigned to a test (n=121) or a validation population (n=114). RESULTS The highest accuracy--91%--for significant fibrosis was obtained with the FibroMeter whose (i) AUROC (0.943) was significantly higher than those of NFSA (0.884, p=0.008) and APRI (0.866, p<10(-3); p=0.309 vs NFSA) in the whole population, and (ii) misclassification rate (9%) was significantly lower than those of NFSA (14%, p=0.04) and APRI (16%, p=0.002) and did not vary according to centre (14 vs 7%, p=0.07), unlike those of NFSA (25 vs 9%, p=0.001) and APRI (29 vs 11%, p<10(-3)). By using thresholds of 90% predictive values, liver biopsy could have been avoided in most patients: FibroMeter: 97.4% vs NFSA: 86.8% (p<10(-3)) and APRI: 80.0% (p<10(-3)). A new classification provided three reliable diagnosis intervals: F0/1, F0/1/2, F2/3/4 with 91.4% accuracy for FibroMeter, avoiding biopsy in all patients. CONCLUSIONS FibroMeter NAFLD had high performance and provided reliable diagnosis for significant fibrosis, significantly outperforming NFSA and APRI.
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Poynard T, Ingiliz P, Elkrief L, Munteanu M, Lebray P, Morra R, Messous D, Bismut FI, Roulot D, Benhamou Y, Thabut D, Ratziu V. Concordance in a world without a gold standard: a new non-invasive methodology for improving accuracy of fibrosis markers. PLoS One 2008; 3:e3857. [PMID: 19052646 PMCID: PMC2586659 DOI: 10.1371/journal.pone.0003857] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 11/08/2008] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Assessing liver fibrosis is traditionally performed by biopsy, an imperfect gold standard. Non-invasive techniques, liver stiffness measurements (LSM) and biomarkers [FibroTest(R) (FT)], are widely used in countries where they are available. The aim was to identify factors associated with LSM accuracy using FT as a non-invasive endpoint and vice versa. METHODS The proof of concept was taken using the manufacturers recommendations for excluding patients at high risk of false negative/positive. The hypothesis was that the concordance between LSM and FT, would be improved by excluding high-risk patients. Thereafter, the impact of potential variability factors was assessed by the same methods. Liver biopsy and independent endpoints were used to validate the results. RESULTS Applying manufacturers' recommendations in 2,004 patients increased the strength of concordance between LSM and FT (P<0.00001). Among the 1,338 patients satisfying recommendations, the methodology identified a significant LSM operator effect (P = 0.001) and the following variability factors (all P<0.01), related to LSM: male gender, older age, and NAFLD as a cause of liver disease. Biopsy confirmed in 391 patients these results. CONCLUSION This study has validated the concept of using the strength of concordance between non-invasive estimates of liver fibrosis for the identification of factors associated with variability and precautions of use.
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Affiliation(s)
- Thierry Poynard
- APHP Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR, Paris, France.
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Evaluation and improvement of a reliable diagnosis of cirrhosis by blood tests. ACTA ACUST UNITED AC 2008; 32:1050-60. [DOI: 10.1016/j.gcb.2008.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 07/30/2008] [Accepted: 09/16/2008] [Indexed: 12/19/2022]
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