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Gao J, Flick A, Allen A, Krasnoff M, Kinder D, Nguyen T. Variability in Liver Size Measurements Using Different View Angles in Ultrasound Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 39248553 DOI: 10.1002/jum.16570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 08/22/2024] [Accepted: 08/23/2024] [Indexed: 09/10/2024]
Abstract
PURPOSE The aim of this study was to compare liver size measurements in different conventional B-mode ultrasound image (US) field views using magnetic resonance imaging (MRI) measurement as a reference. METHODS After receiving Institutional Review Board approval and informed consent, three operators measured the largest sagittal and transverse dimensions of adult livers on three US image field views (90°, 120°, and 140°) with a single curvilinear transducer. We analyzed the differences in liver size across three image field views using one-way analysis of variance (ANOVA) and examined the correlations between MRI and ultrasound measurements using Spearman regression. We used 95% Bland-Altman limits of agreement (95% LOA) to analyze the confidence interval for liver size measurements between MRI and US. Intra-observer and inter-observer reliability in measuring liver size were assessed using intraclass correlation coefficient (ICC). RESULTS Based on sagittal liver length, 28 adult participants (7 men and 21 women, mean age 43 years) were divided into Group 1 (<17 cm, n = 10) or Group 2 (≥17 cm, n = 18). There was a significant difference in the liver size measurements across the three image field views (P < .001) in both groups. The highest correlation in liver size measurements between MRI and US was with ultra-wide-view (R2 = .87 in sagittal; R2 = .79 in transverse). Bland-Altman LOA also indicated good agreement between MRI and ultra-wide-view measurements. Intra-observer and inter-observer reliability in measuring liver size were good (ICC = 0.82-0.98). CONCLUSION The study suggests that ultrasound ultra-wide-view provides the most accurate liver size measurement and good intra- and inter-operator reliability.
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Affiliation(s)
- Jing Gao
- Rocky Vista University, Montana College of Osteopathic Medicine, Billings, Montana, USA
| | - Andrew Flick
- Rocky Vista University, Montana College of Osteopathic Medicine, Billings, Montana, USA
| | - Austin Allen
- Rocky Vista University, Montana College of Osteopathic Medicine, Billings, Montana, USA
| | - Masha Krasnoff
- Rocky Vista University, Montana College of Osteopathic Medicine, Billings, Montana, USA
| | - Dennis Kinder
- Rocky Vista University, Montana College of Osteopathic Medicine, Billings, Montana, USA
| | - Trinh Nguyen
- Department of Radiology, Billings Clinic, Billings, Montana, USA
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Tacke F, Horn P, Wai-Sun Wong V, Ratziu V, Bugianesi E, Francque S, Zelber-Sagi S, Valenti L, Roden M, Schick F, Yki-Järvinen H, Gastaldelli A, Vettor R, Frühbeck G, Dicker D. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024; 81:492-542. [PMID: 38851997 DOI: 10.1016/j.jhep.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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3
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EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Obes Facts 2024; 17:374-444. [PMID: 38852583 PMCID: PMC11299976 DOI: 10.1159/000539371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024] Open
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Fischer AM, Lechea N, Coxson HO. This Is What Metabolic Dysfunction-Associated Steatotic Liver Disease Looks Like: Potential of a Multiparametric MRI Protocol. Semin Liver Dis 2024; 44:226-238. [PMID: 38806158 DOI: 10.1055/a-2334-8525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent condition with a broad spectrum defined by liver biopsy. This gold standard method evaluates three features: steatosis, activity (ballooning and lobular inflammation), and fibrosis, attributing them to certain grades or stages using a semiquantitative scoring system. However, liver biopsy is subject to numerous restrictions, creating an unmet need for a reliable and reproducible method for MASLD assessment, grading, and staging. Noninvasive imaging modalities, such as magnetic resonance imaging (MRI), offer the potential to assess quantitative liver parameters. This review aims to provide an overview of the available MRI techniques for the three criteria evaluated individually by liver histology. Here, we discuss the possibility of combining multiple MRI parameters to replace liver biopsy with a holistic, multiparametric MRI protocol. In conclusion, the development and implementation of such an approach could significantly improve the diagnosis and management of MASLD, reducing the need for invasive procedures and paving the way for more personalized treatment strategies.
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Affiliation(s)
- Anja M Fischer
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Nazim Lechea
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Harvey O Coxson
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
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Fishman J, O’Connell T, Parrinello CM, Woolley JJ, Bercaw E, Charlton MR. Prevalence of Nonalcoholic Steatohepatitis and Associated Fibrosis Stages Among US Adults Using Imaging-Based vs Biomarker-Based Noninvasive Tests. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:32-43. [PMID: 38370007 PMCID: PMC10871169 DOI: 10.36469/001c.92223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/10/2024] [Indexed: 02/20/2024]
Abstract
Introduction: Nonalcoholic fatty liver disease (NAFLD) is believed to be the most common chronic liver disease worldwide. Therapies are under development for nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, such that the prevalence of NASH with liver fibrosis, which is likely to require treatment, may be of interest to healthcare decision makers. Noninvasive tests are used in initial screening for NASH, as well as in observational studies of NASH prevalence. However, existing evidence does not address how estimated prevalence varies with different noninvasive tests. This analysis estimated the prevalence of NASH among US adults and assessed variation with different noninvasive tests. Methods: A cross-sectional analysis was conducted using the 2017-March 2020 National Health and Nutrition Examination Survey cycle. Participants with presumed NAFLD (steatosis and without alternative causes of liver disease) were identified, among whom NASH was predicted based on FAST score, Fibrosis-4 (FIB-4), and AST-to-Platelet Ratio Index (APRI) cutoffs across 11 scenarios. Among NASH participants, fibrosis stages were explored based on distribution across the spectrum of liver-stiffness measurements. Results: Among participants with complete data for the analysis (N=6969), prevalence of presumed NAFLD was 25.6%. Within presumed NAFLD, prediction of NASH using imaging-based NIT cutoffs yielded estimated prevalence of 1.3%-4.8% (3.3 million-12.2 million) based on FAST score cutoffs from 0.35-0.67. Using biomarker-based NIT cutoffs yielded estimated prevalence of 0.4%-12.3% (1.0 million-14.5 million) based on FIB-4 cutoffs from 0.90-2.67, and 0.1%-1.9% (0.2-5.0 million) based on APRI cutoffs from 0.50-1.50. Conclusion: Prevalence of NASH among US adults was estimated to range from 1.3% to 4.8% when predicted using imaging-based noninvasive test values for participants with presumed NAFLD, generally aligning with estimates in the literature of prevalence of biopsy-confirmed NASH. Use of biomarker-based noninvasive test values for prediction of NASH yielded a wider range of estimates with FIB-4, and a considerably lower range of estimates with APRI.
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Affiliation(s)
- Jesse Fishman
- Madrigal Pharmaceuticals, West Conshohocken, Pennsylvania, USA
| | | | | | | | - Eric Bercaw
- Medicus Economics, Boston, Massachusetts, USA
| | - Michael R. Charlton
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, Illinois, USA
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6
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Wattacheril JJ, Abdelmalek MF, Lim JK, Sanyal AJ. AGA Clinical Practice Update on the Role of Noninvasive Biomarkers in the Evaluation and Management of Nonalcoholic Fatty Liver Disease: Expert Review. Gastroenterology 2023; 165:1080-1088. [PMID: 37542503 DOI: 10.1053/j.gastro.2023.06.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 08/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide clinicians with guidance on the use of noninvasive tests (NITs) in the evaluation and management of patients with nonalcoholic fatty liver disease (NAFLD). NAFLD affects nearly 30% of the global population and is a growing cause of end-stage liver disease and liver-related health care resource utilization. However, only a minority of all patients with NAFLD experience a liver-related outcome. It is therefore critically important for clinicians to assess prognosis and identify those with increased risk of disease progression and negative clinical outcomes at the time of initial assessment. It is equally important to assess disease trajectory over time, particularly in response to currently available therapeutic approaches. The reference standard for assessment of prognosis and disease monitoring is histologic examination of liver biopsy specimens. There are, however, many limitations of liver biopsies and their reading that have limited their use in routine practice. The utilization of NITs facilitates risk stratification of patients and longitudinal assessment of disease progression for patients with NAFLD. This clinical update provides best practice advice based on a review of the literature on the utilization of NITs in the management of NAFLD for clinicians. Accordingly, a combination of available evidence and consensus-based expert opinion, without formal rating of the strength and quality of the evidence, was used to develop these best practice advice statements. METHODS This Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: NITs can be used for risk stratification in the diagnostic evaluation of patients with NAFLD. BEST PRACTICE ADVICE 2: A Fibrosis 4 Index score <1.3 is associated with strong negative predictive value for advanced hepatic fibrosis and may be useful for exclusion of advanced hepatic fibrosis in patients with NAFLD. BEST PRACTICE ADVICE 3: A combination of 2 or more NITs combining serum biomarkers and/or imaging-based biomarkers is preferred for staging and risk stratification of patients with NAFLD whose Fibrosis 4 Index score is >1.3. BEST PRACTICE ADVICE 4: Use of NITs in accordance with manufacturer's specifications (eg, not in patients with ascites or pacemakers) can minimize risk of discordant results and adverse events. BEST PRACTICE ADVICE 5: NITs should be interpreted with context and consideration of pertinent clinical data (eg, physical examination, biochemical, radiographic, and endoscopic) to optimize positive predictive value in the identification of patients with advanced fibrosis. BEST PRACTICE ADVICE 6: Liver biopsy should be considered for patients with NIT results that are indeterminate or discordant; conflict with other clinical, laboratory, or radiologic findings; or when alternative etiologies for liver disease are suspected. BEST PRACTICE ADVICE 7: Serial longitudinal monitoring using NITs for assessment of disease progression or regression may inform clinical management (ie, response to lifestyle modification or therapeutic intervention). BEST PRACTICE ADVICE 8: Patients with NAFLD and NITs results suggestive of advanced fibrosis (F3) or cirrhosis (F4) should be considered for surveillance of liver complications (eg, hepatocellular carcinoma screening and variceal screening per Baveno criteria). Patients with NAFLD and NITs suggestive of advanced hepatic fibrosis (F3) or (F4), should be monitored with serial liver stiffness measurement; vibration controlled transient elastography; or magnetic resonance elastography, given its correlation with clinically significant portal hypertension and clinical decompensation.
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Affiliation(s)
- Julia J Wattacheril
- Division of Digestive and Liver Diseases, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York.
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Joseph K Lim
- Section of Digestive Diseases, Yale Liver Center, Yale University School of Medicine, New Haven, Connecticut
| | - Arun J Sanyal
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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7
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Lazarus JV, Mark HE, Allen AM, Arab JP, Carrieri P, Noureddin M, Alazawi W, Alkhouri N, Alqahtani SA, Arrese M, Bataller R, Berg T, Brennan PN, Burra P, Castro-Narro GE, Cortez-Pinto H, Cusi K, Dedes N, Duseja A, Francque SM, Hagström H, Huang TTK, Wajcman DI, Kautz A, Kopka CJ, Krag A, Miller V, Newsome PN, Rinella ME, Romero D, Sarin SK, Silva M, Spearman CW, Tsochatzis EA, Valenti L, Villota-Rivas M, Zelber-Sagi S, Schattenberg JM, Wong VWS, Younossi ZM. A global research priority agenda to advance public health responses to fatty liver disease. J Hepatol 2023; 79:618-634. [PMID: 37353401 DOI: 10.1016/j.jhep.2023.04.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND & AIMS An estimated 38% of adults worldwide have non-alcoholic fatty liver disease (NAFLD). From individual impacts to widespread public health and economic consequences, the implications of this disease are profound. This study aimed to develop an aligned, prioritised fatty liver disease research agenda for the global health community. METHODS Nine co-chairs drafted initial research priorities, subsequently reviewed by 40 core authors and debated during a three-day in-person meeting. Following a Delphi methodology, over two rounds, a large panel (R1 n = 344, R2 n = 288) reviewed the priorities, via Qualtrics XM, indicating agreement using a four-point Likert-scale and providing written feedback. The core group revised the draft priorities between rounds. In R2, panellists also ranked the priorities within six domains: epidemiology, models of care, treatment and care, education and awareness, patient and community perspectives, and leadership and public health policy. RESULTS The consensus-built fatty liver disease research agenda encompasses 28 priorities. The mean percentage of 'agree' responses increased from 78.3 in R1 to 81.1 in R2. Five priorities received unanimous combined agreement ('agree' + 'somewhat agree'); the remaining 23 priorities had >90% combined agreement. While all but one of the priorities exhibited at least a super-majority of agreement (>66.7% 'agree'), 13 priorities had <80% 'agree', with greater reliance on 'somewhat agree' to achieve >90% combined agreement. CONCLUSIONS Adopting this multidisciplinary consensus-built research priorities agenda can deliver a step-change in addressing fatty liver disease, mitigating against its individual and societal harms and proactively altering its natural history through prevention, identification, treatment, and care. This agenda should catalyse the global health community's efforts to advance and accelerate responses to this widespread and fast-growing public health threat. IMPACT AND IMPLICATIONS An estimated 38% of adults and 13% of children and adolescents worldwide have fatty liver disease, making it the most prevalent liver disease in history. Despite substantial scientific progress in the past three decades, the burden continues to grow, with an urgent need to advance understanding of how to prevent, manage, and treat the disease. Through a global consensus process, a multidisciplinary group agreed on 28 research priorities covering a broad range of themes, from disease burden, treatment, and health system responses to awareness and policy. The findings have relevance for clinical and non-clinical researchers as well as funders working on fatty liver disease and non-communicable diseases more broadly, setting out a prioritised, ranked research agenda for turning the tide on this fast-growing public health threat.
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Affiliation(s)
- Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA.
| | - Henry E Mark
- European Association for the Study of the Liver (EASL), Geneva, Switzerland; Independent Consultant, Nottingham, UK
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada; Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patrizia Carrieri
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - Mazen Noureddin
- Houston Methodist Hospital, Houston Research Institute, Houston, TX, USA
| | - William Alazawi
- Barts Liver Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Naim Alkhouri
- Fatty Liver Program, Arizona Liver Health, Phoenix, AZ, USA
| | - Saleh A Alqahtani
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Marco Arrese
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ramon Bataller
- Liver Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Paul N Brennan
- Division of Hepatology, University of Dundee, Dundee, Scotland, UK
| | - Patrizia Burra
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology at the Padua University Hospital, Padua, Italy
| | - Graciela E Castro-Narro
- Department of Hepatology and Transplant, Hospital Médica Sur, Mexico City, Mexico; Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Asociación Latinoamericana para el Estudio del Hígado (ALEH), Santiago, Chile
| | - Helena Cortez-Pinto
- Clinica Universitária de Gastrenterologia, Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sven M Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium; InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Hannes Hagström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Terry T-K Huang
- CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA; CUNY Center for Systems and Community Design and NYU-CUNY Prevention Research Center, New York, NY, USA
| | - Dana Ivancovsky Wajcman
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Veronica Miller
- University California Berkeley School of Public Health, Berkeley, CA, USA
| | - Philip N Newsome
- National Institute for Health Research Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
| | - Mary E Rinella
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Diana Romero
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Marcelo Silva
- Hepatology and Clinical Research Units, Hospital Universitario Austral, Buenos Aires, Argentina
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Luca Valenti
- Precision Medicine, Biological Resource Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marcela Villota-Rivas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; Department of Gastroenterology, Tel Aviv Medical Centre, Tel Aviv, Israel
| | - Jörn M Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
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8
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Allen AM, Lazarus JV, Younossi ZM. Healthcare and socioeconomic costs of NAFLD: A global framework to navigate the uncertainties. J Hepatol 2023; 79:209-217. [PMID: 36740046 PMCID: PMC10293095 DOI: 10.1016/j.jhep.2023.01.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 02/07/2023]
Abstract
Left unaddressed, non-alcoholic fatty liver disease (NAFLD) will continue to have substantial health, economic and social implications. To address the challenge, a paradigm shift is needed in the way NAFLD is conceptualised. Concerted, collaborative action across medical specialities, industry sectors and governments will be vital in tackling this public health threat. To drive this change, in this review, we present data on the current global healthcare and socioeconomic costs of NAFLD and highlight priority actions. The estimated healthcare costs of patients with NAFLD are nearly twice as high as their age-matched counterparts without the disease and are highest in those with advanced fibrosis and end-stage liver disease. NAFLD is accountable for the highest increase in DALYs (disability-adjusted life years) among all liver diseases globally. NAFLD and non-alcoholic steatohepatitis (NASH)-specific drug therapies are not yet available and there is considerable uncertainty regarding cost, optimal length of treatment, and their impact on liver-related outcomes and mortality. Among the currently available bariatric procedures, sleeve gastrectomy is reported to be the most cost-effective for NASH resolution. Gastric bypass remains very expensive, while data on bariatric endoscopy are limited. Lastly, we propose a global NAFLD/NASH investment framework to guide the development of achievable yet ambitious country-specific targets and strategic actions to optimise resource allocation and reduce the prevalence of NAFLD and NASH. Its focus on high-level inputs will be critical to enabling a political and financial environment that supports clinical-level implementation of NAFLD prevention, treatment and care efforts, across all settings.
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Affiliation(s)
- Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Zobair M Younossi
- Center for Liver Diseases, Inova Medicine, Falls Church, Virginia, USA
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9
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Younossi ZM, Stepanova M, Felix S, Jeffers T, Younossi E, Goodman Z, Racila A, Lam BP, Henry L. The combination of the enhanced liver fibrosis and FIB-4 scores to determine significant fibrosis in patients with nonalcoholic fatty liver disease. Aliment Pharmacol Ther 2023; 57:1417-1422. [PMID: 36967586 DOI: 10.1111/apt.17472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 12/26/2022] [Accepted: 03/07/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The presence of fibrosis in NAFLD is the most significant risk factor for adverse outcomes. We determined the cutoff scores of two non-invasive te sts (NITs) to rule in and rule out significant fibrosis among NAFLD patients. METHODS Clinical data and liver biopsies were used for NAFLD patients included in this analysis (2001-2020). The enhanced liver fibrosis (ELF) and FIB-4 NITs were calculated. Liver biopsies were read by a single hematopathologist and scored by the NASH CRN criteria. Significant fibrosis was defined as stage F2-F4. RESULTS There were 463 NAFLD patients included: 48 ± 13 years old, 31% male, 35% type 2 diabetes; 39% had significant fibrosis; mean ELF score was 9.0 ± 1.2, mean FIB-4 score was 1.22 ± 1.05. Patients with significant fibrosis were older, more commonly male, had lower BMI but more components of metabolic syndrome, higher ELF and FIB-4 (p < 0.0001). The performance of the two NITs in identifying significant fibrosis was: AUC (95% CI) = 0.78 (0.74-0.82) for ELF, 0.79 (0.75-0.83) for FIB-4. The combination of ELF score ≥9.8 and FIB-4 ≥ 1.96 returned a positive predictive value of 95% which can reliably rule in significant fibrosis (sensitivity 22%, specificity >99%), while an ELF score ≤7.7 or FIB-4 ≤ 0.30 had a negative predictive value of 95% ruling out significant fibrosis (sensitivity 98%, specificity 22%). CONCLUSIONS The combination of ELF and FIB-4 may provide practitioners with easily obtained information to risk stratify patients with NAFLD who could be referred to specialists or for enrollment in clinical trials.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Maria Stepanova
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia, USA
| | - Sean Felix
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Thomas Jeffers
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Elena Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Andrei Racila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Brian P Lam
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
| | - Linda Henry
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Inova Medicine Service Line, Inova Health System, Falls Church, Virginia, USA
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia, USA
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10
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Dunn W, Castera L, Loomba R. Roles of Radiological Tests in Clinical Trials and the Clinical Management of Nonalcoholic Fatty Liver Disease. Clin Liver Dis 2023; 27:363-372. [PMID: 37024213 PMCID: PMC10792514 DOI: 10.1016/j.cld.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Radiological testing is now routinely used for clinical trial prescreening, diagnosis, and treatment and referral. The CAP performs well in detecting fatty liver but is unable to grade and track longitudinal changes. MRI-PDFF is a better technique for evaluating longitudinal changes and is used as a primary endpoint in trials of antisteatotic agents. The probability of detecting liver fibrosis using radiological testing techniques is high when performed at referral centers, and reasonable imaging strategies include the combination of FIB-4 and VCTE, the FAST Score, MAST, and MEFIB. The strategy currently recommended is the sequential application of FIB-4 and VCTE.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Laurent Castera
- Université de Paris, UMR1149 (CRI), INSERM, Paris, France; Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, Clichy, France
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, NAFLD Research Center, University of California San Diego, La Jolla, CA, USA
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11
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Sangha K, Chang ST, Cheung R, Deshpande VS. Cost-effectiveness of MRE versus VCTE in staging fibrosis for nonalcoholic fatty liver disease (NAFLD) patients with advanced fibrosis. Hepatology 2023; 77:1702-1711. [PMID: 37018145 DOI: 10.1097/hep.0000000000000262] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/14/2022] [Indexed: 04/06/2023]
Abstract
INTRODUCTION NAFLD is a common cause of liver disease. To determine the optimal testing strategy for NAFLD patients with advanced fibrosis, several factors such as diagnostic accuracy, failure rates, costs of examinations, and potential treatment options need to be considered. The purpose of this study was to determine the cost-effectiveness of combination testing involving vibration-controlled transient elastography (VCTE) versus magnetic resonance elastography (MRE) as a frontline imaging strategy for NAFLD patients with advanced fibrosis. METHODS A Markov model was developed from the US perspective. The base-case scenario in this model included patients aged 50 years with a Fibrosis-4 score of ≥2.67 and suspected advanced fibrosis. The model included a decision tree and a Markov state-transition model including 5 health states: fibrosis stage 1-2, advanced fibrosis, compensated cirrhosis, decompensated cirrhosis, and death. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS Staging fibrosis with MRE cost $8388 more than VCTE but led to an additional 1.19 Quality-adjusted life years (QALYs) with the incremental cost-effectiveness ratio of $7048/QALY. The cost-effectiveness analysis of the 5 strategies revealed that MRE+biopsy and VCTE+MRE+biopsy were the most cost-effective with the incremental cost-effectiveness ratios of $8054/QALY and $8241/QALY, respectively. Furthermore, sensitivity analyses indicated that MRE remained cost-effective with a sensitivity of ≥0.77, whereas VCTE became cost-effective with a sensitivity of ≥0.82. CONCLUSIONS MRE was not only cost-effective than VCTE as the frontline modality for staging NAFLD patients with Fibrosis-4 ≥2.67 with incremental cost-effectiveness ratio of $7048/QALY but also remained cost-effective when used as a follow-up in instances of VCTE failure to diagnose.
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Affiliation(s)
| | - Stephanie T Chang
- Department of Radiology, VA Palo Alto Healthcare System California, USA
- Department of Medicine, VA Palo Alto Healthcare System, California, USA
| | - Ramsey Cheung
- Stanford University, Palo Alto, California, USA
- Department of Medicine, VA Palo Alto Healthcare System, California, USA
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12
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Forlano R, Sigon G, Mullish BH, Yee M, Manousou P. Screening for NAFLD-Current Knowledge and Challenges. Metabolites 2023; 13:metabo13040536. [PMID: 37110194 PMCID: PMC10144613 DOI: 10.3390/metabo13040536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver function tests worldwide, with an estimated prevalence ranging between 19-46% in the general population. Of note, NAFLD is also expected to become a leading cause of end-stage liver disease in the next decades. Given the high prevalence and severity of NAFLD, especially in high-risk populations (i.e., patients with type-2 diabetes mellitus and/or obesity), there is a major interest in early detection of the disease in primary care. Nevertheless, substantial uncertainties still surround the development of a screening policy for NAFLD, such as limitations in currently used non-invasive markers of fibrosis, cost-effectiveness and the absence of a licensed treatment. In this review, we summarise current knowledge and try to identify the limitations surrounding the screening policy for NAFLD in primary care.
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Affiliation(s)
- Roberta Forlano
- Liver Unit, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London W21NY, UK
| | - Giordano Sigon
- Liver Unit, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London W21NY, UK
| | - Benjamin H Mullish
- Liver Unit, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London W21NY, UK
| | - Michael Yee
- Liver Unit, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London W21NY, UK
| | - Pinelopi Manousou
- Liver Unit, Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London W21NY, UK
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13
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Lara Romero C, Liang JX, Fernández Lizaranzazu I, Ampuero Herrojo J, Castell J, Del Prado Alba C, Domínguez Pascual I, Romero Gómez M. Liver stiffness accuracy by magnetic resonance elastography in histologically proven non-alcoholic fatty liver disease patients: a Spanish cohort. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:162-167. [PMID: 35791792 DOI: 10.17235/reed.2022.8777/2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES to evaluate the performance of magnetic resonance elastography (MRE) to stage liver fibrosis in patients with histologically confirmed nonalcoholic fatty liver disease (NAFLD) and to assess the impact of potential confounding factors in MRE diagnostic accuracy. The secondary objective was to compare MRE with other non-invasive methods for staging fibrosis such as transient elastography (TE) and non-invasive scores (APRI and FIB-4). METHODS sixty-five histologically confirmed NAFLD patients were prospectively enrolled at the Hospital Universitario Virgen del Rocío (Seville, Spain). Liver stiffness was measured by MRE, TE and non-invasive scores (APRI and FIB-4). Fibrosis was assessed by liver biopsy using the steatosis, activity and fibrosis (SAF) score. Patients were classified into three groups according to the consistency between MRE and histopathological findings: underestimation, concordance and overestimation groups. Areas under the ROC curve (AUROC) and diagnostic performance were evaluated. RESULTS the area under the ROC curve (AUROC) of MRE in advanced fibrosis (≥ F3) was 0.90 (0.82-0.97), while TE AUROC was 0.82 (0.72-0.93) (p = 0.22) and lower for the non-invasive test (FIB-4 0.67 and APRI 0.62). Inflammatory activity, steatosis grade and higher levels of liver biochemistry appeared to overestimate MRE results in the univariate analysis, but only gamma-glutamyl transferase (GGT) was statistically significant in the multivariate analysis (p < 0.01). Age, sex, body mass index (BMI), weight, diabetes mellitus (DM), high blood pressure (HBP), platelets or lipidic profile did not affect MRE accuracy. CONCLUSIONS MRE is an effective and non-invasive method for detecting and staging liver fibrosis in NAFLD patients. MRE is more accurate than TE and allows the study of liver anatomy. Histological inflammation and surrogate biomarkers of inflammation can overestimate liver stiffness, but only GGT was statistically significant in the multivariate analysis. Important features of NAFLD patients such as obesity, DM, or lipidic profile did not affect MRE accuracy.
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Affiliation(s)
| | - Jia-Xu Liang
- Radiodiagnóstico, Hospital Universitario Virgen del Rocío, España
| | | | | | - Javier Castell
- Radiodiagnóstico, Hospital Universitario Virgen del Rocío, España
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14
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Romero-Gómez M, Aller R, Ampuero J, Fernández Rodríguez C, Augustín S, Latorre R, Rivera-Esteban J, Martínez Urroz B, Gutiérrez García ML, López SA, Albillos A, Hernández M, Graupera I, Benlloch S, Olveira A, Crespo J, Calleja JL. AEEH «Consensus about detection and referral of hidden prevalent liver diseases». GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:236-247. [PMID: 35569541 DOI: 10.1016/j.gastrohep.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/02/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Manuel Romero-Gómez
- Servicio de Aparato Digestivo, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (HUVR/CSIC/US), Universidad de Sevilla, Sevilla, España.
| | - Rocío Aller
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Universidad de Valladolid, Valladolid, España
| | - Javier Ampuero
- Servicio de Aparato Digestivo, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (HUVR/CSIC/US), Universidad de Sevilla, Sevilla, España
| | | | - Salvador Augustín
- Servei de Hepatología, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Raquel Latorre
- Servicio de Aparato Digestivo, Hospital Universitario Son Llàtzer, Palma de Mallorca, Islas Baleares, España
| | | | | | | | - Sonia Alonso López
- Servicio de Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Agustín Albillos
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Marta Hernández
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro-Majadahonda, IDIPHISA, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Isabel Graupera
- Servicio de Hepatología, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, España
| | - Salvador Benlloch
- Servicio de Aparato Digestivo, Hospital Arnau de Vilanova, Valencia, España; CIBERehd, Instituto de Salud Carlos III, Madrid, España
| | - Antonio Olveira
- Servicio de Aparato Digestivo, Hospital La Paz, Madrid, España
| | - Javier Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla. IDIVAL, Santander, Cantabria, España
| | - José Luis Calleja
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro-Majadahonda, IDIPHISA, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
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15
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Buckholz AP, Brown RS. Noninvasive Fibrosis Testing in Chronic Liver Disease Including Caveats. Clin Liver Dis 2023; 27:117-131. [PMID: 36400461 DOI: 10.1016/j.cld.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Assessment of liver fibrosis is important as the range of liver disease management has expanded, rendering biopsy both imperfect and impractical in many situations. Noninvasive tests of fibrosis leverage laboratory, imaging and elastography techniques to estimate disease extent, often with the goal of identifying advanced fibrosis. This review attempts to summarize their utility across a broad range of possible clinical scenarios while considering the central tenets of health care quality: access, quality, and cost. For each test, it also discusses the caveats whereby each test may have reduced effectiveness and how to consider each in a typical clinical setting.
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Affiliation(s)
- Adam P Buckholz
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian/Weill Cornell Medical Center, 1305 York Avenue 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian/Weill Cornell Medical Center, 1305 York Avenue 4th Floor, New York, NY 10021, USA.
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16
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Zhang S, Mak LY, Yuen MF, Seto WK. Screening strategy for non-alcoholic fatty liver disease. Clin Mol Hepatol 2023; 29:S103-S122. [PMID: 36447420 PMCID: PMC10029948 DOI: 10.3350/cmh.2022.0336] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, affecting approximately 25% of the general population worldwide, and is forecasted to increase global health burden in the 21st century. With the advancement of non-invasive tests for assessing and monitoring of steatosis and fibrosis, NAFLD screening is now feasible, and is increasingly highlighted in international guidelines related to hepatology, endocrinology, and pediatrics. Identifying high-risk populations (e.g., diabetes mellitus, obesity, metabolic syndrome) based on risk factors and metabolic characteristics for non-invasive screening is crucial and may aid in designing screening strategies to be more precise and effective. Many screening modalities are currently available, from serum-based methods to ultrasonography, transient elastography, and magnetic resonance imaging, although the diagnostic performance, cost, and accessibility of different methods may impact the actual implementation. A two-step assessment with serum-based fibrosis-4 index followed by imaging test vibration-controlled transient elastography can be an option to stratify the risk of liverrelated complications in NAFLD. There is a need for fibrosis surveillance, as well as investigating the cost-effectiveness of different screening algorithms and engaging primary care for first-stage triage screening.
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Affiliation(s)
- Saisai Zhang
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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17
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Pugliese N, Alfarone L, Arcari I, Giugliano S, Parigi TL, Rescigno M, Lleo A, Aghemo A. Clinical features and management issues of NAFLD-related HCC: what we know so far. Expert Rev Gastroenterol Hepatol 2023; 17:31-43. [PMID: 36576057 DOI: 10.1080/17474124.2023.2162503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) is replacing viral hepatitis as the leading cause of chronic liver disease and hepatocellular carcinoma (HCC) in many Western countries. NAFLD-associated HCC usually affects older patients with multiple comorbidities, frequently develops in the absence of cirrhosis, and is often diagnosed later with worse chance of survival. The worse prognosis is also due to limited surveillance strategies and a lower efficacy of standard treatments. AREAS COVERED We evaluate the available literature to understand the current surveillance strategies and treatment limitations in the workup of NAFLD-associated HCC, focusing on the differences with HCC associated with other liver diseases. EXPERT OPINION In this review we discuss epidemiology and risk factors for HCC in NAFLD patients and address key HCC surveillance and management issues. Although most data are still preliminary, the detection of non-cirrhotic NAFLD patients at increased risk for HCC and the potential adoption of novel screening tools could lead to accurate and suitable HCC surveillance and management strategies for NAFLD patients.
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Affiliation(s)
- Nicola Pugliese
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Ludovico Alfarone
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Ivan Arcari
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Silvia Giugliano
- Laboratory of Mucosal Immunology and Microbiota, IRCCS Humanitas Research Hospital - IRCCS, via Manzoni 56, 20089 Rozzano, Italy
| | | | - Maria Rescigno
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Laboratory of Mucosal Immunology and Microbiota, IRCCS Humanitas Research Hospital - IRCCS, via Manzoni 56, 20089 Rozzano, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessio Aghemo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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18
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Kim BK, Tamaki N, Imajo K, Yoneda M, Sutter N, Jung J, Lin T, Tu XM, Bergstrom J, Nguyen K, Nguyen L, Le T, Madamba E, Richards L, Valasek MA, Behling C, Sirlin CB, Nakajima A, Loomba R. Head-to-head comparison between MEFIB, MAST, and FAST for detecting stage 2 fibrosis or higher among patients with NAFLD. J Hepatol 2022; 77:1482-1490. [PMID: 35973577 DOI: 10.1016/j.jhep.2022.07.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/29/2022] [Accepted: 07/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Patients with non-alcoholic fatty liver disease (NAFLD) and significant fibrosis (fibrosis stage ≥2) are candidates for pharmacological trials. The aim of this study was to perform a head-to-head comparison of the diagnostic test characteristics of three non-invasive stiffness-based models including MEFIB (magnetic resonance elastography [MRE] plus FIB-4), MAST (magnetic resonance imaging [MRI]-aspartate aminotransferase [AST]), and FAST (FibroScan-AST) for detecting significant fibrosis. METHODS This prospective study included 563 patients with biopsy-proven NAFLD undergoing contemporaneous MRE, MRI proton density fat fraction (MRI-PDFF) and FibroScan from two prospective cohorts derived from Southern California and Japan. Diagnostic performances of models were evaluated by area under the receiver-operating characteristic curve (AUC). RESULTS The mean age of the cohort was 56.5 years (51% were women). Significant fibrosis was observed in 51.2%. To detect significant fibrosis, MEFIB outperformed both MAST and FAST (both p <0.001); AUCs for MEFIB, MAST, and FAST were 0.901 (95% CI 0.875-0.928), 0.770 (95% CI 0.730-0.810), and 0.725 (95% CI 0.683-0.767), respectively. Using rule-in criteria, the positive predictive value of MEFIB (95.3%) was significantly higher than that of FAST (83.5%, p = 0.001) and numerically but not statistically greater than that of MAST (90.0%, p = 0.056). Notably, MEFIB's rule-in criteria covered more of the study population than MAST (34.1% vs. 26.6%; p = 0.006). Using rule-out criteria, the negative predictive value of MEFIB (90.1%) was significantly higher than that of either MAST (69.6%) or FAST (71.8%) (both p <0.001). Furthermore, to diagnose "at risk" non-alcoholic steatohepatitis defined as NAFLD activity score ≥4 and fibrosis stage ≥2, MEFIB outperformed both MAST and FAST (both p <0.05); AUCs for MEFIB, MAST, and FAST were 0.768 (95% CI 0.728-0.808), 0.719 (95% CI 0.671-0.766), and 0.687 (95% CI 0.640-0.733), respectively. CONCLUSIONS MEFIB was better than MAST and FAST for detection of significant fibrosis as well as "at risk" NASH. All three models provide utility for the risk stratification of NAFLD. LAY SUMMARY Non-alcoholic fatty liver disease (NAFLD) affects over 25% of the general population worldwide and is one of the main causes of chronic liver disease. Because so many individuals have NAFLD, it is not practical to perform liver biopsies to identify those with more severe disease who may require pharmacological interventions. Therefore, accurate non-invasive tests are crucial. Herein, we compared three such tests and found that a test called MEFIB was the best at detecting patients who might require treatment.
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Affiliation(s)
- Beom Kyung Kim
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States; Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nobuharu Tamaki
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States; Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan; Department of Gastroenterology, Shin-yurigaoka General Hospital, Kanagawa, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Nancy Sutter
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Jinho Jung
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Tuo Lin
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Xin M Tu
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Jaclyn Bergstrom
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Khang Nguyen
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Leyna Nguyen
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Tracy Le
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Egbert Madamba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Lisa Richards
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Mark A Valasek
- Department of Pathology, University of California San Diego, La Jolla, CA, United States
| | - Cynthia Behling
- Sharp Medical Group, Department of Pathology, University of California San Diego, La Jolla, CA, United States
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, CA, United States
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, United States; Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, United States.
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19
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Liu YB, Chen MK. Epidemiology of liver cirrhosis and associated complications: Current knowledge and future directions. World J Gastroenterol 2022; 28:5910-5930. [PMID: 36405106 PMCID: PMC9669831 DOI: 10.3748/wjg.v28.i41.5910] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/30/2022] [Accepted: 10/20/2022] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis causes a heavy global burden. In this review, we summarized up-to-date epidemiological features of cirrhosis and its complications. Recent epidemiological studies reported an increase in the prevalence of cirrhosis in 2017 compared to in 1990 in both men and women, with 5.2 million cases of cirrhosis and chronic liver disease occurring in 2017. Cirrhosis caused 1.48 million deaths in 2019, an increase of 8.1% compared to 2017. Disability-adjusted life-years due to cirrhosis ranked 16th among all diseases and 7th in people aged 50-74 years in 2019. The global burden of hepatitis B virus and hepatitis C virus-associated cirrhosis is decreasing, while the burden of cirrhosis due to alcohol and nonalcoholic fatty liver disease (NAFLD) is increasing rapidly. We described the current epidemiology of the major complications of cirrhosis, including ascites, variceal bleeding, hepatic encephalopathy, renal disorders, and infections. We also summarized the epidemiology of hepatocellular carcinoma in patients with cirrhosis. In the future, NAFLD-related cirrhosis will likely become more common due to the prevalence of metabolic diseases such as obesity and diabetes, and the prevalence of alcohol-induced cirrhosis is increasing. This altered epidemiology should be clinically noted, and relevant interventions should be undertaken.
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Affiliation(s)
- Yuan-Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Ming-Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
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20
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Behari J. Needle-free Nonalcoholic Fatty Liver Disease Prognostication: Moving One Step Closer. Gastroenterology 2022; 163:819-822. [PMID: 35944709 DOI: 10.1053/j.gastro.2022.07.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Jaideep Behari
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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21
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Li J, Yin M. Liver Fibrosis: Counterpoint-MR Elastography Is the Noninvasive Imaging Modality of Choice for Detecting and Staging Liver Fibrosis. AJR Am J Roentgenol 2022; 219:384-385. [PMID: 35319909 PMCID: PMC9558097 DOI: 10.2214/ajr.22.27676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jiahui Li
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Meng Yin
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
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22
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Castera L, Boursier J. Noninvasive Algorithms for the Case Finding of "At-Risk" Patients with NAFLD. Semin Liver Dis 2022; 42:313-326. [PMID: 35835440 DOI: 10.1055/s-0042-1751081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Despite the high prevalence of non-alcoholic fatty liver disease (NAFLD) in primary care (25%), only a small minority (< 5%) of NAFLD patients will develop advanced liver fibrosis. The challenge is to identify these patients, who are at the greatest risk of developing complications and need to be referred to liver clinics for specialized management. The focus should change from patients with abnormal liver tests toward patients "at risk of NAFLD," namely those with metabolic risk factors, such as obesity and type 2 diabetes. Non-invasive tests are well validated for diagnosing advanced fibrosis. Algorithms using FIB-4 as the first-line test, followed, if positive (≥ 1.3), by transient elastography or a patented blood test are the best strategy to define pathways for "at-risk" NAFLD patients from primary care to liver clinics. Involving general practitioners actively and raising their awareness regarding NAFLD and non-invasive tests are critical to establish such pathways.
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Affiliation(s)
- Laurent Castera
- Université de Paris, UMR1149 (CRI), INSERM, Paris, France.,Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, Clichy, France
| | - Jérôme Boursier
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France.,Laboratoire HIFIH UPRES EA3859, SFR ICAT 4208, Université d'Angers, Angers, France
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23
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Tamaki N, Kurosaki M, Huang DQ, Loomba R. Noninvasive assessment of liver fibrosis and its clinical significance in nonalcoholic fatty liver disease. Hepatol Res 2022; 52:497-507. [PMID: 35352460 PMCID: PMC9718363 DOI: 10.1111/hepr.13764] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/11/2022] [Accepted: 03/28/2022] [Indexed: 01/26/2023]
Abstract
Liver fibrosis is the most important prognostic factor in patients with nonalcoholic fatty liver disease (NAFLD). Several noninvasive markers for fibrosis, including blood-based markers and imaging based-markers have been developed. Indirect fibrosis markers (e.g., fibrosis-4 index and NAFLD fibrosis score) consist of standard laboratory data and clinical parameters. Given its availability and high negative predictive value for advanced fibrosis, these markers are suitable for screening at primary care. Blood-based fibrogenesis markers (enhanced liver fibrosis and N-terminal propeptide of type 3 collagen), ultrasound-based modalities (vibration-controlled transient elastography, point shear wave elastography [SWE], and two-dimensional SWE), and magnetic resonance elastography have high diagnostic accuracy for liver fibrosis and are suitable for diagnosing liver fibrosis at secondary care centers. Sequential use of these markers can increase diagnostic accuracy and reduce health care costs. Furthermore, combining noninvasive makers may assist in identifying candidates for pharmacological trials and reducing screening failure. Emerging data suggest that these noninvasive markers are associated with liver-related events (hepatocellular carcinoma and decompensation) and mortality. Furthermore, delta change in noninvasive markers over time is also associated with time-course change in fibrosis, liver-related event risk, and mortality risk. However, the association between liver fibrosis and cardiovascular disease (CVD) risk is still controversial. CVD risk may decrease in patients with decompensated liver disease and noninvasive markers may be useful for assessing CVD risk in these patients. Therefore, noninvasive markers may be utilized as measures of fibrosis as well as real-time prognostic tools, in place of liver biopsy.
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Affiliation(s)
- Nobuharu Tamaki
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Daniel Q. Huang
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
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24
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Anstee QM, Castera L, Loomba R. Impact of non-invasive biomarkers on hepatology practice: Past, present and future. J Hepatol 2022; 76:1362-1378. [PMID: 35589256 DOI: 10.1016/j.jhep.2022.03.026] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022]
Abstract
Over the last two decades, there have been tremendous advances in the non-invasive diagnosis and risk stratification of chronic liver diseases (CLDs). Non-invasive approaches are based on the quantification of biomarkers in serum samples or on the measurement of liver stiffness, using either ultrasound- or magnetic resonance-based elastography techniques. The fibrosis-4 index (non-patented) and enhanced liver fibrosis test (patented) are the most widely adopted serum markers, whereas vibration-controlled transient elastography is the most widely adopted elastography technique. In this review, we discuss the role of non-invasive tests in the current era, as well as their accuracy and how their use in clinical practice has changed the practice of hepatology, including identification of early cirrhosis in patients with risk factors for CLD, diagnosis of portal hypertension, establishing prognosis in compensated cirrhosis, guiding antiviral treatment, and screening for fibrosis and cirrhosis in primary care.
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Affiliation(s)
- Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
| | - Laurent Castera
- Université de Paris, UMR1149 (CRI), Inserm, F-75018 Paris, France; Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, F-92110 Clichy-la-Garenne, France.
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, University of California at San Diego, La Jolla, CA, United States; Herbert Wertheim School of Public Health, University of California at San Diego, La Jolla, CA, United States.
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25
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Non-invasive tests accurately stratify patients with NAFLD based on their risk of liver-related events. J Hepatol 2022; 76:1013-1020. [PMID: 35063601 DOI: 10.1016/j.jhep.2021.12.031] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 11/20/2021] [Accepted: 12/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Previous studies on the prognostic significance of non-invasive liver fibrosis tests in non-alcoholic fatty liver disease (NAFLD) lack direct comparison to liver biopsy. We aimed to evaluate the prognostic accuracy of fibrosis-4 (FIB4) and vibration-controlled transient elastography (VCTE), compared to liver biopsy, for the prediction of liver-related events (LREs) in NAFLD. METHODS A total of 1,057 patients with NAFLD and baseline FIB4 and VCTE were included in a multicenter cohort. Of these patients, 594 also had a baseline liver biopsy. The main study outcome during follow-up was occurrence of LREs, a composite endpoint combining cirrhosis complications and/or hepatocellular carcinoma. Discriminative ability was evaluated using Harrell's C-index. RESULTS FIB4 and VCTE showed good accuracy for the prediction of LREs, with Harrell's C-indexes >0.80 (0.817 [0.768-0.866] vs. 0.878 [0.835-0.921], respectively, p = 0.059). In the biopsy subgroup, Harrell's C-indexes of histological fibrosis staging and VCTE were not significantly different (0.932 [0.910-0.955] vs. 0.881 [0.832-0.931], respectively, p = 0.164), while both significantly outperformed FIB4 for the prediction of LREs. FIB4 and VCTE were independent predictors of LREs in the whole study cohort. The stepwise FIB4-VCTE algorithm accurately stratified the risk of LREs: compared to patients with "FIB4 <1.30", those with "FIB4 ≥1.30 then VCTE <8.0 kPa" had similar risk of LREs (adjusted hazard ratio [aHR] 1.3; 95% CI 0.3-6.8), whereas the risk of LREs significantly increased in patients with "FIB4 ≥1.30 then VCTE 8.0-12.0 kPa" (aHR 3.8; 95% CI 1.3-10.9), and even more for those with "FIB4 ≥1.30 then VCTE >12.0 kPa" (aHR 12.4; 95% CI 5.1-30.2). CONCLUSION VCTE and FIB4 accurately stratify patients with NAFLD based on their risk of LREs. These non-invasive tests are alternatives to liver biopsy for the identification of patients in need of specialized management. LAY SUMMARY The amount of fibrosis in the liver is closely associated with the risk of liver-related complications in non-alcoholic fatty liver disease (NAFLD). Liver biopsy currently remains the reference standard for the evaluation of fibrosis, but its application is limited by its invasiveness. Therefore, we evaluated the ability of non-invasive liver fibrosis tests to predict liver-related complications in NAFLD. Our results show that the blood test FIB4 and transient elastography stratify the risk of liver-related complications in NAFLD, and that transient elastography has similar prognostic accuracy as liver biopsy. These results support the use of non-invasive liver fibrosis tests instead of liver biopsy for the management of patients with NAFLD.
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Identifying Advanced Fibrosis in NAFLD Using Noninvasive Tests: A Systematic Review of Sequential Algorithms. J Clin Gastroenterol 2022; 56:266-272. [PMID: 33780219 DOI: 10.1097/mcg.0000000000001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/27/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND The utility of noninvasive tests (NITs) for the diagnosis of advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is limited by indeterminate results and modest predictive values (PVs). Algorithms of sequential NITs may overcome these shortcomings. Thus, we sought to systematically review the accuracy of sequential algorithms for assessing advanced fibrosis in NAFLD. METHODS A systematic review was performed following guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A literature search of PubMed and Embase was performed in July of 2020 to identify studies that evaluated diagnostic characteristics of sequential NIT algorithms in NAFLD. RESULTS Among 8 studies meeting inclusion criteria, 48 algorithms were studied in 6741 patients. The average sensitivity, specificity, positive PV, negative PV, and proportion of indeterminate values for included algorithms were 72%, 92%, 88%, 82%, and 25%, respectively. Six algorithms achieved sensitivities in the top quartile (≥86.3%) with <25% indeterminate values. Four algorithms achieved specificities in the top quartile (≥98.7%) with <25% indeterminate values. The aforementioned algorithms included combinations of Fibrosis-4, NAFLD fibrosis score, and vibration-controlled transient elastography. CONCLUSIONS Sequential NIT algorithms may reduce indeterminate results while achieving sensitivities comparable to single NITs. Sequential algorithms may also augment the specificities of single NITs, though resulting positive PVs may not be high enough to obviate the need for liver biopsy. Available evidence supports the use of Fibrosis-4, NAFLD fibrosis score, and vibration-controlled transient elastography within sequential algorithms to achieve diagnostic accuracy for advanced fibrosis in NAFLD.
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Tamaki N, Imajo K, Sharpton S, Jung J, Kawamura N, Yoneda M, Valasek MA, Behling C, Sirlin CB, Nakajima A, Loomba R. Magnetic resonance elastography plus Fibrosis-4 versus FibroScan-aspartate aminotransferase in detection of candidates for pharmacological treatment of NASH-related fibrosis. Hepatology 2022; 75:661-672. [PMID: 34496054 PMCID: PMC9683538 DOI: 10.1002/hep.32145] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Patients with NAFLD with significant hepatic fibrosis (Stage ≥ 2) are at increased risk of liver-related morbidity and are candidates for pharmacologic therapies. In this study, we compared the diagnostic accuracy of MEFIB (the combination of magnetic resonance elastography [MRE] and Fibrosis-4 [FIB-4]) and FAST (FibroScan-aspartate aminotransferase; combined liver stiffness measurement by vibration-controlled transient elastography, controlled attenuation parameter, and aspartate aminotransferase) for detecting significant fibrosis. APPROACH AND RESULTS This prospective cohort study included 234 consecutive patients with NAFLD who underwent liver biopsy, MRE, and FibroScan at the University of California San Diego (UCSD cohort) and an independent cohort (N = 314) from Yokohama City University, Japan. The primary outcome was diagnostic accuracy for significant fibrosis (Stage ≥ 2). The proportions of significant fibrosis in the UCSD and Yokohama cohorts were 29.5% and 66.2%, respectively. Area under the receiver operating characteristic curve (95% CI) of MEFIB (0.860 [0.81-0.91]) was significantly higher than that of FAST (0.757 [0.69-0.82]) in the UCSD cohort (p = 0.005), with consistent results in the Yokohama cohort (AUROC, 0.899 [MEFIB] versus 0.724 [FAST]; p < 0.001). When used as the rule-in criteria (MEFIB, MRE ≥ 3.3 kPa and FIB-4 ≥ 1.6; FAST ≥ 0.67), the positive predictive value for significant fibrosis was 91.2%-96.0% for MEFIB and 74.2%-89.2% for FAST. When used as the rule-out criteria (MEFIB, MRE < 3.3 kPa and FIB-4 < 1.6; FAST ≤ 0.35), the negative predictive value for significant fibrosis was 85.6%-92.8% for MEFIB and 57.8%-88.3% for FAST. CONCLUSIONS MEFIB has higher diagnostic accuracy than FAST for significant fibrosis in NAFLD, and our results support the utility of a two-step strategy for detecting significant fibrosis in NAFLD.
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Affiliation(s)
- Nobuharu Tamaki
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA,Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan,Department of Gastroenterology, Shin-yurigaoka General Hospital, Kanagawa, Japan
| | - Suzanne Sharpton
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jinho Jung
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Nobuyoshi Kawamura
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan,Department of Gastroenterology, Shin-yurigaoka General Hospital, Kanagawa, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Mark A. Valasek
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Cynthia Behling
- Sharp Medical Group, Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California, USA,Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
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28
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Segura-Azuara NDLÁ, Varela-Chinchilla CD, Trinidad-Calderón PA. MAFLD/NAFLD Biopsy-Free Scoring Systems for Hepatic Steatosis, NASH, and Fibrosis Diagnosis. Front Med (Lausanne) 2022; 8:774079. [PMID: 35096868 PMCID: PMC8792949 DOI: 10.3389/fmed.2021.774079] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022] Open
Abstract
Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly known as nonalcoholic fatty liver disease, is the most prevalent liver disorder worldwide. Historically, its diagnosis required biopsy, even though the procedure has a variable degree of error. Therefore, new non-invasive strategies are needed. Consequently, this article presents a thorough review of biopsy-free scoring systems proposed for the diagnosis of MAFLD. Similarly, it compares the severity of the disease, ranging from hepatic steatosis (HS) and nonalcoholic steatohepatitis (NASH) to fibrosis, by contrasting the corresponding serum markers, clinical associations, and performance metrics of these biopsy-free scoring systems. In this regard, defining MAFLD in conjunction with non-invasive tests can accurately identify patients with fatty liver at risk of fibrosis and its complications. Nonetheless, several biopsy-free scoring systems have been assessed only in certain cohorts; thus, further validation studies in different populations are required, with adjustment for variables, such as body mass index (BMI), clinical settings, concomitant diseases, and ethnic backgrounds. Hence, comprehensive studies on the effects of age, morbid obesity, and prevalence of MAFLD and advanced fibrosis in the target population are required. Nevertheless, the current clinical practice is urged to incorporate biopsy-free scoring systems that demonstrate adequate performance metrics for the accurate detection of patients with MAFLD and underlying conditions or those with contraindications of biopsy.
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29
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Jung J, Loomba RR, Imajo K, Madamba E, Gandhi S, Bettencourt R, Singh S, Hernandez C, Valasek MA, Behling C, Richards L, Fowler K, Sirlin C, Nakajima A, Loomba R. MRE combined with FIB-4 (MEFIB) index in detection of candidates for pharmacological treatment of NASH-related fibrosis. Gut 2021; 70:1946-1953. [PMID: 33214165 PMCID: PMC8131405 DOI: 10.1136/gutjnl-2020-322976] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Patients with non-alcoholic fatty liver disease (NAFLD) with ≥stage 2 fibrosis are at increased risk for liver-related mortality and are candidates for pharmacological therapies for treatment of NAFLD. The aim of this prospective cohort study is to examine the diagnostic accuracy of MR elastography (MRE) combined with fibrosis-4 (FIB-4) in diagnosing ≥stage 2 fibrosis (candidates for pharmacological therapies). DESIGN This is a cross-sectional analysis of a prospective cohort (University of California at San Diego (UCSD)-NAFLD) including 238 consecutive patients with contemporaneous MRE and biopsy-proven NAFLD. Non-alcoholic steatohepatitis-Clinical Research Network-Histologic Scoring System was used to assess histology. The radiologist and pathologist were blinded to clinical, pathological and imaging data, respectively. Receiver operating characteristics (ROCs) were determined to examine the diagnostic accuracy of MRE and FIB-4 for diagnosis of ≥stage 2 fibrosis in NAFLD. We then validated these findings in an independent validation cohort derived from Yokohama City University in Japan (Japan-NAFLD Cohort; N=222 patients). RESULTS In the UCSD-NAFLD (training) Cohort, MRE demonstrated a clinically significant diagnostic accuracy for the detection of ≥stage 2 fibrosis with an area under the ROC curve (AUROC) of 0.93 (95% CI 0.90 to 0.97) vs FIB-4 with an AUROC of 0.78 (95% CI 0.71 to 0.85), which was both clinically and statistically significant (p<0.0001). We then combined MRE with FIB-4 (MRE ≥3.3 kPa and FIB-4 ≥1.6) to develop a clinical prediction rule to rule in ≥stage 2 fibrosis patients which had positive predictive value (PPV) of 97.1% (p<0.02) in the UCSD-NAFLD cohort (AUROC of 0.90 (95% CI 0.85 to 0.95)) which remained significant at PPV of 91.0% (p<0.003) in the Japan-NAFLD Cohort (AUROC of 0.84 (95% CI 0.78 to 0.89)). CONCLUSION MRE combined with FIB-4 (MEFIB) index may be used for non-invasive identification of candidates for (≥stage 2 fibrosis) pharmacological therapy among patients with NAFLD with a high PPV.
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Affiliation(s)
- Jinho Jung
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Rohan R Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Kento Imajo
- Yokohama City University Graduate School of Medicine, Department of Gastroenterology, Yokohama, Japan
| | - Egbert Madamba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Sanil Gandhi
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Ricki Bettencourt
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Seema Singh
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Carolyn Hernandez
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Mark A. Valasek
- University of California at San Diego, Department of Pathology, La Jolla, United States
| | - Cynthia Behling
- Sharp Medical Group, Department of Pathology, San Diego, United States
| | - Lisa Richards
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, United States
| | - Kathryn Fowler
- University of California at San Diego, Liver Imaging Group, Department of Radiology, La Jolla, United States
| | - Claude Sirlin
- University of California at San Diego, Liver Imaging Group, Department of Radiology, La Jolla, United States
| | - Atsushi Nakajima
- Yokohama City University Graduate School of Medicine, Department of Gastroenterology, Yokohama, Japan
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA .,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
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30
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Diagnostic accuracy of ultrasound-guided attenuation parameter as a noninvasive test for steatosis in non-alcoholic fatty liver disease. J Med Ultrason (2001) 2021; 48:471-480. [PMID: 34415481 DOI: 10.1007/s10396-021-01123-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to evaluate the diagnostic accuracy of the ultrasound-guided attenuation parameter (UGAP) using the LOGEQ E10 for hepatic steatosis in non-alcoholic fatty liver disease (NAFLD) patients and directly compare UGAP with attenuation imaging (ATI) and controlled attenuation parameter (CAP). We prospectively analyzed 105 consecutive patients with NAFLD who underwent UGAP, ATI, CAP, and liver biopsy on the same day between October 2019 and April 2021. The diagnostic ability of the UGAP-determined attenuation coefficient (AC) was evaluated using receiver operating characteristic (ROC) curve analysis, and its correlation with ATI-determined AC values or CAP values was investigated. The success rate of UGAP was 100%. The median IQR/med obtained by UGAP was 4.0%, which was lower than that of ATI and CAP (P < 0.0001). The median ACs obtained by UGAP for grades S0 (control), S1, S2, and S3 were 0.590, 0.670, 0.750, and 0.845 dB/cm/MHz, respectively, demonstrating a stepwise increase with increasing hepatic steatosis severity (P < 0.0001). The areas under the ROC curve of UGAP for identifying ≥ S1, ≥ S2, and S3 were 0.890, 0.906, and 0.912, respectively, which were significantly better than the results obtained with CAP for identifying S3. Furthermore, the correlation coefficient between UGAP-AC and ATI-AC values was 0.803 (P < 0.0001), indicating a strong relationship. Our results indicate that UGAP has high diagnostic accuracy for detecting and grading hepatic steatosis in patients with NAFLD.
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Sofias AM, De Lorenzi F, Peña Q, Azadkhah Shalmani A, Vucur M, Wang JW, Kiessling F, Shi Y, Consolino L, Storm G, Lammers T. Therapeutic and diagnostic targeting of fibrosis in metabolic, proliferative and viral disorders. Adv Drug Deliv Rev 2021; 175:113831. [PMID: 34139255 PMCID: PMC7611899 DOI: 10.1016/j.addr.2021.113831] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/30/2021] [Accepted: 06/10/2021] [Indexed: 02/07/2023]
Abstract
Fibrosis is a common denominator in many pathologies and crucially affects disease progression, drug delivery efficiency and therapy outcome. We here summarize therapeutic and diagnostic strategies for fibrosis targeting in atherosclerosis and cardiac disease, cancer, diabetes, liver diseases and viral infections. We address various anti-fibrotic targets, ranging from cells and genes to metabolites and proteins, primarily focusing on fibrosis-promoting features that are conserved among the different diseases. We discuss how anti-fibrotic therapies have progressed over the years, and how nanomedicine formulations can potentiate anti-fibrotic treatment efficacy. From a diagnostic point of view, we discuss how medical imaging can be employed to facilitate the diagnosis, staging and treatment monitoring of fibrotic disorders. Altogether, this comprehensive overview serves as a basis for developing individualized and improved treatment strategies for patients suffering from fibrosis-associated pathologies.
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Affiliation(s)
- Alexandros Marios Sofias
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany; Mildred Scheel School of Oncology (MSSO), Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO(ABCD)), University Hospital Aachen, Aachen, Germany; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Federica De Lorenzi
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Quim Peña
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Armin Azadkhah Shalmani
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Mihael Vucur
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty at Heinrich-Heine-University, Duesseldorf, Germany
| | - Jiong-Wei Wang
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore, Singapore; Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fabian Kiessling
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Yang Shi
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Lorena Consolino
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.
| | - Gert Storm
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Targeted Therapeutics, University of Twente, Enschede, the Netherlands.
| | - Twan Lammers
- Department of Nanomedicine and Theranostics, Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, Aachen, Germany; Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Targeted Therapeutics, University of Twente, Enschede, the Netherlands.
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Vuppalanchi R, Loomba R. Noninvasive Tests to Phenotype Nonalcoholic Fatty Liver Disease: Sequence and Consequences of Arranging the Tools in the Tool Box. Hepatology 2021; 73:2095-2098. [PMID: 33545738 DOI: 10.1002/hep.31734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, University of California at San Diego, La Jolla, CA
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Congly SE, Shaheen AA, Swain MG. Modelling the cost effectiveness of non-alcoholic fatty liver disease risk stratification strategies in the community setting. PLoS One 2021; 16:e0251741. [PMID: 34019560 PMCID: PMC8139490 DOI: 10.1371/journal.pone.0251741] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/01/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Identifying high-risk patients is critical to best utilize limited health care resources. We established a community-based care pathway using 2D ultrasound shear wave elastography (SWE) to identify high risk patients with NAFLD. Our objective was to assess the cost-effectiveness of various non-invasive strategies to correctly identify high-risk patients. METHODS A decision-analytic model was created using a payer's perspective for a hypothetical patient with NAFLD. FIB-4 [≥1.3], NAFLD fibrosis score (NFS) [≥-1.455], SWE [≥8 kPa], transient elastography (TE) [≥8 kPa], and sequential strategies with FIB-4 or NFS followed by either SWE or TE were compared to identify patients with either significant (≥F2) or advanced fibrosis (≥F3). Model inputs were obtained from local data and published literature. The cost/correct diagnosis of advanced NAFLD was obtained and univariate sensitivity analysis was performed. RESULTS For ≥F2 fibrosis, FIB-4/SWE cost $148.75/correct diagnosis while SWE cost $276.42/correct diagnosis, identifying 84% of patients correctly. For ≥F3 fibrosis, using FIB-4/SWE correctly identified 92% of diagnoses and dominated all other strategies. The ranking of strategies was unchanged when stratified by normal or abnormal ALT. For ≥F3 fibrosis, the cost/correct diagnosis was less in the normal ALT group. CONCLUSIONS SWE based strategies were the most cost effective for diagnosing ≥F2 fibrosis. For ≥F3 fibrosis, FIB-4 followed by SWE was the most effective and least costly strategy. Further evaluation of the timing of repeating non-invasive strategies are required to enhance the cost-effective management of NAFLD.
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Affiliation(s)
- Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary Alberta, Canada
- * E-mail:
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary Alberta, Canada
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
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Braillon A. Screening for Cirrhosis in People With Fatty Liver? Clin Gastroenterol Hepatol 2021; 19:850-851. [PMID: 33248094 DOI: 10.1016/j.cgh.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
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Role of Noninvasive Tests in Clinical Gastroenterology Practices to Identify Patients With Nonalcoholic Steatohepatitis at High Risk of Adverse Outcomes: Expert Panel Recommendations. Am J Gastroenterol 2021; 116:254-262. [PMID: 33284184 DOI: 10.14309/ajg.0000000000001054] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is generally considered a silent and potentially reversible condition. The subtype of NAFLD that can be classified as nonalcoholic steatohepatitis (NASH) can progress to advanced fibrosis and cirrhosis. Because of the metabolic nature of the pathogenic mechanism underlying NAFLD and NASH, it is often accompanied by common comorbidities such as obesity, insulin resistance, and type 2 diabetes mellitus. The increase in the prevalence of these comorbidities has resulted in a parallel increase in the prevalence of NAFLD and NASH, globally, nationally, and even in children. In recent years, it has been identified that the stage of fibrosis is the most important predictor of liver outcomes; therefore, identifying patients with NAFLD and NASH with more advanced stages of fibrosis can be essential for optimal management. Several noninvasive tools for diagnosing and staging NAFLD and NASH are available, but simple and straightforward recommendations on the use of these tools are not. Recognizing these unmet needs, hepatologists who are members of the American College of Gastroenterology and the Chronic Liver Disease Foundation created a practical decision tree/algorithm to risk stratify NAFLD/NASH as a resource in gastroenterology/hepatology clinical practices. This review will provide insight into how this algorithm was developed, describe it in detail, and provide recommendations for its use in clinical practice.
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Vieira Barbosa J, Lai M. Nonalcoholic Fatty Liver Disease Screening in Type 2 Diabetes Mellitus Patients in the Primary Care Setting. Hepatol Commun 2021; 5:158-167. [PMID: 33553966 PMCID: PMC7850314 DOI: 10.1002/hep4.1618] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/10/2020] [Accepted: 09/12/2020] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a major public health problem worldwide and the most common chronic liver disease. NAFLD currently affects approximately one in every four people in the United States, and its global burden is expected to rise in the next decades. Despite being a prevalent disease in the general population, only a minority of patients with NAFLD will develop nonalcoholic steatohepatitis (NASH) with advanced liver fibrosis (stage 3-4 fibrosis) and liver-related complications. Certain populations, such as patients with type 2 diabetes mellitus (T2DM), are recognized to be at the highest risk for developing NASH and advanced fibrosis. Both the American Diabetes Association and the European Association for the Study of Diabetes recommend screening of all T2DM for NAFLD. Incorporating a simple noninvasive algorithm into the existing diabetic care checklists in the primary care practice or diabetologist's office would efficiently identify patients at high risk who should be referred to specialists. The proposed algorithm involves a first-step annual fibrosis-4 score (FIB-4) followed by vibration-controlled transient elastography (VCTE) for those with indeterminate or high-risk score (FIB-4 ≥1.3). Patients at low-risk (FIB-4 <1.3 or VCTE <8 kPa) can be followed up by primary care providers for lifestyle changes and yearly calculation of FIB-4, while patients at high risk (FIB-4 ≥1.3 and VCTE ≥8 kPa) should be referred to a liver-specialized center. Conclusion: Patients with T2DM or prediabetes should be screened for NASH and advanced fibrosis. The proposed simple algorithm can be easily incorporated into the existing workflow in the primary care or diabetology clinic to identify patients at high risk for NASH and advanced fibrosis who should be referred to liver specialists.
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Affiliation(s)
- Joana Vieira Barbosa
- Division of Gastroenterology and HepatologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA.,Division of Gastroenterology and HepatologyUniversity Hospital of Lausanne and University of LausanneLausanneSwitzerland
| | - Michelle Lai
- Division of Gastroenterology and HepatologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA
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Ajmera V, Loomba R. Imaging biomarkers of NAFLD, NASH, and fibrosis. Mol Metab 2021; 50:101167. [PMID: 33460786 PMCID: PMC8324681 DOI: 10.1016/j.molmet.2021.101167] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022] Open
Abstract
Background Non-alcoholic fatty liver disease (NAFLD) is a clinicopathologic entity that requires a liver biopsy assessment to diagnose the progressive form of NAFLD called non-alcoholic steatohepatitis (NASH). Liver biopsy is invasive, subject to sampling and interobserver variability, and impractical to scale to the affected population of up to 1 billion affected individuals worldwide. Non-invasive imaging biomarkers have emerged as a key modality to address the major unmet need to diagnose, stage, and longitudinally monitor NAFLD. Scope of review In this review, we critically examine the use of non-invasive imaging biomarkers to diagnose NAFLD, NASH, and fibrosis stage. Major Conclusions Ultrasound and magnetic resonance imaging (MRI) biomarkers of liver fat can diagnose NAFLD. MRI proton density fat fraction (MRI-PDFF) is better than liver biopsy, particularly for following longitudinal changes in liver fat in clinical trials. Imaging biomarkers to reliably diagnose NASH are under investigation, but when used alone, continue to have only modest diagnostic accuracy. However, the fibrosis stage has the strongest association with liver decompensation and mortality, and elastography has emerged as a reliable biomarker for liver fibrosis. We review the combination of biomarkers to risk stratify patients and identify individuals needing treatment and the implications of longitudinal changes in liver stiffness measurement. An improvement of ≥30% in liver fat on MRI-PDFF is associated with histologic improvement. Combining MRE ≥3.3 kPa and FIB-4 ≥ 1.6 (MEFIB Index) predicts high-risk NAFLD. Elevated liver stiffness measurements predict future hepatic decompensation. MRE ≥ 4.67 kPa and ≥8 kPa predict cirrhosis and hepatic decompensation, respectively.
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Affiliation(s)
- Veeral Ajmera
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA.
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA.
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Boursier J, Tsochatzis EA. Case-finding strategies in non-alcoholic fatty liver disease. JHEP Rep 2020; 3:100219. [PMID: 33659890 PMCID: PMC7896150 DOI: 10.1016/j.jhepr.2020.100219] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Among the large population of patients with non-alcoholic fatty liver disease (NAFLD), identifying those with advanced disease remains challenging. Many patients are diagnosed late, following the development of liver-related complications, leading to poor clinical outcomes. Accumulating evidence suggests that using non-invasive tests for liver fibrosis in patients with metabolic risk factors improves the detection of patients in need of specialised management and is cost-effective. Because of the vast number of patients requiring evaluation, the active participation of general practitioners and physicians who manage patients with metabolic disorders, such as diabetologists, is crucial; this calls for the increased awareness of NAFLD beyond liver clinics. Non-invasive case-finding strategies will need to be further validated and generalised for upcoming drug therapies to have the required impact on the worldwide burden of NAFLD.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Awareness
- Case-finding
- Cirrhosis
- Cost-effectiveness
- ELF, enhanced liver fibrosis
- Elastography
- FIB-4
- FIB-4, fibrosis-4
- GP, general practitioner
- Liver fibrosis
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- NFS, NAFLD fibrosis score
- NICE, National Institute of Clinical Excellence
- NIT, non-invasive test
- Patient pathway
- Primary care
- QALY, quality-adjusted life year
- Screening
- T2DM, type 2 diabetes mellitus
- TE, transient elastography
- Type 2 diabetes mellitus
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Affiliation(s)
- Jerome Boursier
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France.,Laboratoire HIFIH, UPRES EA3859, SFR 4208, Université d'Angers, Angers, France
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK.,UCL Institute for Liver and Digestive Health, Royal Free Campus, UCL, London, UK
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