Performance of Enhanced Liver Fibrosis test and comparison with transient elastography in the identification of liver fibrosis in patients with chronic hepatitis B infection

Meta-analysis: Enhanced liver fibrosis test to identify hepatic fibrosis in chronic liver diseases

BACKGROUND & AIMS

Patients with liver disease can be stratified for risk of liver-related ill health by degree of hepatic fibrosis. The Enhanced liver fibrosis (ELF) test was developed to quantify hepatic fibrosis non-invasively and is widely used. The objective of this review was to identify and synthesise the evidence on the diagnostic accuracy of the ELF test for staging of hepatic fibrosis.

APPROACH & RESULTS

Searches of PubMed and EMBASE were conducted between October 2020 and November 2021 to identify studies reporting the diagnostic accuracy of the ELF test compared to histology in liver disease patients. QUADAS-2 was used to assess risk of bias in each study. Meta-analysis using the multiple thresholds model described by Steinhauser S, Schumacher M, Rücker G. Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies. BMC Med. Res. Methodol. 2016;16. 10.1186/s12874-016-0196-1 allowed synthesis of 2 × 2 data at different cut-offs. Sixty-three studies were included in this review. These studies included 19,285 patients with or at risk of liver disease from viral hepatitis, Non-Alcoholic Fatty Liver Disease, Alcohol-related Liver Disease and other mixed chronic liver diseases. The prevalence of significant fibrosis, advanced fibrosis and cirrhosis was 47.5%, 39.2% and 4.4%, respectively. Cut-offs with maximal Youden index were generated with AUROC = 0.811 (95% CI: 0.736-0.870), 0.812 (95% CI: 0.758-0.856) and 0.810 (95% CI: 0.694-0.888) to detect significant fibrosis, advanced fibrosis or cirrhosis, respectively. Diagnostic accuracy of the ELF test varied between different liver diseases and cut-offs to detect each stage with 95% sensitivity or specificity were also generated.

CONCLUSIONS

Meta-analysis revealed considerable variability in the ability of ELF to stage fibrosis across disease aetiologies. Research has mostly focused on viral hepatitis and NAFLD. There is currently a lack of data on the value of the ELF test in Alcohol-related liver disease and patients in primary care settings.

Enhanced liver fibrosis score as a noninvasive biomarker in hepatitis C virus patients after direct-acting antiviral agents

Background: In more than 90% of chronic viral hepatitis C (HCV) patients treated with direct-acting antiviral agents (DAAs), a sustained viral response (SVR) was observed. Unfortunately, there are subgroups of subjects who display enduring liver fibrosis and are at high risk of developing hepatocellular carcinoma (HCC). Thus, liver fibrosis evaluation during the follow-up of these patients plays a pivotal role. The gold standard to evaluate hepatic fibrosis is liver biopsy, which is an invasive procedure. Imaging techniques and serum biomarkers have been proposed as safer and cheaper procedures.

Objectives: In this study, we evaluated the concordance of transient elastography (TE) with ELF score ( enhanced liver fibrosis) in a cohort of patients with HCV before and after direct-acting antiviral (DAAs) treatment. ELF score has been validated in other chronic liver diseases; the evidence is not available in HCV patients treated with DAAs.

Study design: We prospectively recruited all consecutive HCV patient candidates for DAAs therapy at the University of Naples “Federico II” between April 2015 and July 2016. TE and ELF scores were assessed at baseline, at SVR24, and at SVR48.

Results: One-hundred-nineteen patients were treated with DAAs, and 94.1% of them reached SVR. A total of 55.5% of patients were males with a mean age of 64.7 ± 9.6 years. TE results revealed that 12 patients (10%) had F1-2 mild/moderate fibrosis, and 107 (90%) had F3-4 advanced fibrosis. At baseline, SVR24, and SVR48, the concordance between ELF test and TE was poor: 0.11 (p = 0.086), 0.15 (p = 0.124), and 0.034 (p = 0.002), respectively. However, at SVR24 and SVR48, both methods showed a significant amelioration of liver fibrosis compared to baseline (p < 0.001). In addition, both ELF index and TE were significantly associated with portal hypertension at baseline, but not with varices and ascites.

Conclusions: Our findings suggested that ELF test could predict changes in liver fibrosis, independently of TE. In case of TE unavailability, ELF score could represent an appropriate tool. Notably, in the context of the COVID-19 pandemic, ELF testing should be encouraged to reduce unnecessary access to the hospital and prolonged physical contact.

Enhanced liver fibrosis score as a surrogate of liver-related complications and mortality in primary biliary cholangitis

The presence of bridging fibrosis predicts survival of primary biliary cholangitis (PBC). This study aimed to compare serum parameters for the estimation of liver fibrosis and prediction of clinical outcomes in PBC.Out of 392 patients with PBC, 102 who underwent liver biopsy and in whom fibrosis indices, platelet count, hyaluronic acid, type IV collagen 7 second domain, procollagen type III amino-terminal peptide, tissue inhibitor of metalloproteinases 1, Mac-2 binding protein glycosylation isomer, N-terminal type III collagen propeptide levels; fibrosis index based on 4 factors, aspartate aminotransferase-to-platelet ratio index, and enhanced liver fibrosis (ELF) score were determined, were included. The correlation of histological stages based on both Scheuer and Nakanuma classifications with fibrosis indices was investigated. The Nakanuma system comprises grading for liver fibrosis and bile duct loss. Diagnostic performances of 10 fibrosis indices were evaluated to identify patients with poor prognosis. Moreover, correlations of those with PBC clinical manifestation and survival were also investigated.Enhances liver fibrosis (ELF) score had the highest correlation coefficient for liver fibrosis evaluated according to either the Scheuer or Nakanuma classification among 10 serum fibrosis indices. It also had the highest diagnostic performance in estimating Scheuer stage III and Nakanuma fibrosis score 2, both of which represent portal-bridging fibrosis. Patients with an ELF score of ≥10.0 had shorter survival and presented more frequently clinical complications than those with an ELF score of <10.0.ELF score determines the severity of liver fibrosis and predicts the occurrence of complications and survival in patients with PBC.

The Enhanced Liver Fibrosis Index Predicts Hepatic Fibrosis Superior to FIB4 and APRI in HIV/HCV Infected Patients

BACKGROUND

Accurate noninvasive biomarkers of fibrotic progression are important for hepatitis C virus (HCV) management, but commonly used modalities may have decreased efficacy in human immunodeficiency virus (HIV)/HCV-coinfected persons. The enhanced liver fibrosis (ELF) index is a highly sensitive noninvasive marker of hepatic fibrosis that has had limited assessment in the HIV/HCV population. We compared ELF index performance to FIB4 and aspartate to platelet ratio index (APRI) at different stages of liver fibrosis as determined by liver histology, and validated the efficacy of the three noninvasive biomarkers in HIV/HCV-coinfected versus HCV-monoinfected.

METHODS

The ELF index was determined in 147 HIV/HCV-coinfected and 98 HCV-monoinfected persons using commercial ELISA assays for the component elements of the index. Area under the receiver-operator curve was used to validate ELF and to compare its performance to liver histology as well as to other noninvasive biomarkers of liver fibrosis, FIB4, and APRI.

RESULTS

The ELF index increased with histological stage of liver fibrosis and exhibited a linear relationship with Metavir score in all subjects. ELF performance was comparable between HIV/HCV and HCV with advanced liver fibrosis/cirrhosis. In the HIV/HCV cohort ELF cutoffs of 8.45 and 9.23 predicted mild and moderate fibrosis with 85% sensitivity, whereas the ELF cutoff of 9.8 had the highest specificity for advanced fibrosis and the cutoff of 10.4 was 99% specific for cirrhosis. ELF performance was superior to FIB4 and APRI in all subjects regardless of HIV status.

CONCLUSIONS

ELF index demonstrated excellent characteristics toward accurate prediction of liver fibrosis and cirrhosis with superior performance to APRI and FIB4 in HIV/HCV coinfection. Applying this noninvasive biomarker index for diagnosis of liver fibrosis and progression in HIV/HCV is warranted.

Serum Biomarkers of Liver Fibrosis Staging in the Era of the Concept "Compensated Advanced Chronic Liver Disease"

Non-invasive indexes of liver fibrosis based on blood examinations have been developed for decades, partially replacing liver biopsy examinations. Recently, the concept of liver cirrhosis was revised and converted to "compensated advanced chronic liver diseases" since the Baveno VI consensus statement in 2015. The term "compensated advanced chronic liver diseases" was established based on the premise that serum biomarkers were not able to differentiate cirrhosis from severe fibrosis. The difficulty to histologically distinguish cirrhosis from severe fibrosis had been pointed out in 1977, when the definition and nomenclatures of cirrhosis had been determined by the World Health Organization. That was decades before serum biomarkers available at present were investigated. Though we are accustomed to differentiating the fibrosis stage as stage 1, 2, 3 (severe fibrosis), and 4 (cirrhosis), differentiation of cirrhosis from severe fibrosis is difficult even by histopathological examination. The current review will provide readers a framework to revise how to apply serum biomarkers on liver fibrosis staging in an era of the concept of "compensated advanced chronic liver disease".

Systematic review: Accuracy of the enhanced liver fibrosis test for diagnosing advanced liver fibrosis and cirrhosis

BACKGROUND AND AIMS

The rising incidence of chronic liver disease (CLD) has increased the need for early recognition. This systematic review assesses the diagnostic accuracy of the enhanced liver fibrosis (ELF) test in cases of advanced fibrosis and cirrhosis due to multiple etiologies in at-risk populations.

METHODS

Studies evaluating the ELF accuracy in identifying advanced fibrosis or cirrhosis, defined as METAVIR stage F ≥ 3 and F = 4 or equivalent, in patients with non-alcoholic fatty liver disease (NAFLD), alcohol liver disease (ALD), or viral hepatitis were included. Liver biopsy was used as the reference standard. Medline and Embase databases were searched. The QUADAS-2 tool was used as a framework to assess risk of bias and applicability. The area under the receiver operator curve (AUROC) was extracted as a summary measure of diagnostic accuracy.

RESULTS

Thirty-six studies were included: 11 hepatitis C, 4 hepatitis B, 9 NAFLD, 2 ALD, and 10 mixed. The ELF test showed good diagnostic performance in detecting advanced fibrosis in patients with viral hepatitis (AUROC 0.69 to 0.98) and excellent performance in NAFLD (AUROC 0.78 to 0.97) and ALD (AUROC from 0.92 to 0.94). There is also evidence of good diagnostic performance for detecting cirrhosis in patients with viral hepatitis (AUROC 0.63 to 0.99), good performance in NAFLD (AUROC 0.85 to 0.92), and excellent performance in patients with ALD (AUROC 0.93 to 0.94).

CONCLUSION

This systematic review supports the use of the ELF test across a range of CLD as a possible alternative to liver biopsy in selected cases.

Advances in non-invasive assessment of hepatic fibrosis

Liver fibrosis should be assessed in all individuals with chronic liver disease as it predicts the risk of future liver-related morbidity and thus need for treatment, monitoring and surveillance. Non-invasive fibrosis tests (NITs) overcome many limitations of liver biopsy and are now routinely incorporated into specialist clinical practice. Simple serum-based tests (eg, Fibrosis Score 4, non-alcoholic fatty liver disease Fibrosis Score) consist of readily available biochemical surrogates and clinical risk factors for liver fibrosis (eg, age and sex). These have been extensively validated across a spectrum of chronic liver diseases, however, tend to be less accurate than more 'complex' serum tests, which incorporate direct measures of fibrogenesis or fibrolysis (eg, hyaluronic acid, N-terminal propeptide of type three collagen). Elastography methods quantify liver stiffness as a marker of fibrosis and are more accurate than simple serum NITs, however, suffer increasing rates of unreliability with increasing obesity. MR elastography appears more accurate than sonographic elastography and is not significantly impacted by obesity but is costly with limited availability. NITs are valuable for excluding advanced fibrosis or cirrhosis, however, are not sufficiently predictive when used in isolation. Combining serum and elastography techniques increases diagnostic accuracy and can be used as screening and confirmatory tests, respectively. Unfortunately, NITs have not yet been demonstrated to accurately reflect fibrosis change in response to treatment, limiting their role in disease monitoring. However, recent studies have demonstrated lipidomic, proteomic and gut microbiome profiles as well as microRNA signatures to be promising techniques for fibrosis assessment in the future.

The Enhanced Liver Fibrosis test is associated with liver-related outcomes in postmenopausal women with risk factors for liver disease

BACKGROUND

Chronic liver disease (CLD) is usually asymptomatic but earlier detection is critical to permit life-saving interventions for those at risk due to high alcohol consumption and increased body mass index (BMI). The aim of this study was to estimate the association between the Enhanced Liver Fibrosis (ELF) test and liver-related events (LRE) and its performance in predicting LRE in postmenopausal women with risk factors in a nested case-control study within the United Kingdom Trial of Ovarian Cancer Screening (UKCTOCS).

METHODS

In a cohort of 95,126 we performed a case-control study measuring ELF in blinded samples from 173 participants with self-reported high alcohol use and / or BMI ≥25 kg/m2 comprising all 58 cases who developed LRE and 115 controls matched for age, alcohol and BMI who did not develop LRE during median follow-up of 8.5 years.

RESULTS

Using Cox regression at an ELF threshold of 10.51 hazard ratios (HR) for LRE were 4.88 (95% confidence interval (CI) 2.37-10.03) (unadjusted model) and 4.62 (95% CI 2.12-10.08) (adjusted for deprivation and self-reported hypertension, heart disease, hypercholesterolaemia and diabetes). At a threshold of 9.8 HR for LRE were 2.21 (95% CI 1.22-3.97) (unadjusted model) and 2.18 (95% CI 1.19-4.01) (adjusted). ELF was evaluated as a time dependent variable by generating time-dependent Cox models; HRs at an ELF threshold of 10.51 were 1.94 (95% CI 1.10-3.39) (unadjusted) and 2.05 (95% CI 1.16-3.64) (adjusted) and at a threshold of 9.8 HRs were 1.85 (95% CI 1.09-3.15) (unadjusted) and 1.80 (95% CI 1.04-3.13) (adjusted). Area under the receiver operating characteristic curve for recruitment ELF predicting LRE was 0.58 (95% CI 0.49-0.68), and for second subsequent ELF 0.61 (95% CI 0.52-0.71).

CONCLUSION

This study demonstrates the association between ELF and CLD in postmenopausal women with risk factors for liver disease, creating the opportunity to intervene to reduce liver-related mortality and morbidity. Although larger studies are required, these results demonstrate the potential of ELF as a prognostic tool in health checks in primary care.

TRIAL REGISTRATION

This study is nested in UKCTOCS. UKCTOCS is registered as an International Standard Randomised Controlled Trial, number ISRCTN22488978. Registered 06/04/2000.

Derivation and Performance of Standardized Enhanced Liver Fibrosis (ELF) Test Thresholds for the Detection and Prognosis of Liver Fibrosis

INTRODUCTION

Noninvasive tests are increasingly used to assess liver fibrosis and determine prognosis but suggested test thresholds vary. We describe the selection of standardized thresholds for the Enhanced Liver Fibrosis (ELF) test for the detection of liver fibrosis and for prognostication in chronic liver disease.

METHODS

A Delphi method was used to identify thresholds for the ELF test to predict histological liver fibrosis stages, including cirrhosis, using data derived from 921 patients in the EUROGOLF cohort. These thresholds were then used to determine the prognostic performance of ELF in a subset of 457 patients followed for a mean of 5 years.

RESULTS

The Delphi panel selected sensitivity of 85% for the detection of fibrosis and >95% specificity for cirrhosis. The corresponding thresholds were 7.7, 9.8, and 11.3. Eighty-five percent of patients with mild or worse fibrosis had an ELF score ≥7.7. The sensitivity for cirrhosis of ELF ≥9.8 was 76%. ELF ≥11.3 was 97% specific for cirrhosis. ELF scores show a near-linear relationship with Ishak fibrosis stages. Relative to the <7.7 group, the hazard ratios for a liver-related outcome at 5 years were 21.00 (95% CI, 2.68-164.65) and 71.04 (95% CI, 9.4-536.7) in the 9.8 to <11.3 and ≥11.3 subgroups, respectively.

CONCLUSION

The selection of standard thresholds for detection and prognosis of liver fibrosis is described and their performance reported. These thresholds should prove useful in both interpreting and explaining test results and when considering the relationship of ELF score to Ishak stage in the context of monitoring.

Combination of Transient Elastography and an Enhanced Liver Fibrosis Test to Assess the Degree of Liver Fibrosis in Patients with Chronic Hepatitis B

Background/Aims

Liver stiffness (LS) was assessed using transient elastography, and the enhanced liver fibrosis (ELF) test was performed to accurately assess fibrotic burden. We validated the LS-ELF algorithm and investigated whether the sequential LS-ELF algorithm performs better than concurrent combination of these analyses in chronic hepatitis B (CHB) patients.

Methods

Between 2009 and 2013, 222 CHB patients who underwent liver biopsy (LB), as well as LS measurement and the ELF test, were enrolled.

Results

Advanced fibrosis (≥F3) and cirrhosis (F4) were identified in 141 (63.6%) and 118 (53.2%) patients, respectively. Areas under receiver operating characteristic curve for LS predictions of ≥F3 (0.887 vs 0.703) and F4 (0.853 vs 0.706) were significantly higher than the ELF test (all p＜0.001). Based on the LS-ELF algorithm, 60.4% to 71.6% and 55.7% to 66.3% of patients could have avoided LB to exclude ≥F3 and F4, respectively, whereas 68.0% to 78.7% and 63.5% to 66.1% of patients could have avoided LB to confirm ≥F3 and F4, respectively. When confirmation and exclusion strategies were applied simultaneously, 69.4% to 72.5% and 60.8% to 65.3% of patients could have avoided LB and been diagnosed as ≥F3 and F4, respectively. The proportion of patients who correctly avoided LB for the prediction of ≥F3 (69.4% to 72.5% vs 42.3% to 59.0%) and F4 (60.8% to 65.3% vs 23.9% to 49.5%) based on the sequential LS-ELF algorithm was significantly higher than the concurrent combination (all p＜0.05).

Conclusions

The sequential LS-ELF algorithm conferred a greater probability of avoiding LB in CHB patients to diagnose advanced fibrosis and cirrhosis, and this test performed significantly better than the concurrent combination.

Transient Elastography for Significant Liver Fibrosis and Cirrhosis in Chronic Hepatitis B: A Meta-Analysis

BACKGROUND

The hepatitis B virus infection is a global health issue and the stage of liver fibrosis affects the prognosis in patients with chronic hepatitis B (CHB). We performed the meta-analysis describing diagnostic accuracy of transient elastography (TE) for predicting CHB-related fibrosis.

METHODS

We performed an adequate literature search to identify studies that assessed the diagnostic accuracy of TE in CHB patients using biopsy as reference standard. Hierarchical summary receiver-operating curves model and the bivariate mixed-effects binary regression model were applied to generate summary receiver-operating characteristic curves and pooled estimates of sensitivity and specificity.

RESULTS

The area under the summary receiver-operating curve for significant fibrosis and cirrhosis was 0.86 (95% confidence interval (CI): 0.83-0.89) and 0.92 (95% CI: 0.90-0.94), respectively. The sensitivity, specificity, and diagnostic odds ratio of TE for significant fibrosis were 0.78 (95% CI: 0.73-0.81, p < 0.01; I² = 85.59%), 0.81 (95% CI: 0.77-0.84, p < 0.01; I² = 88.20%), and 14.44 (95% CI: 10.80-19.31, p < 0.01; I² = 100%) and for cirrhosis were 0.84 (95% CI: 0.80-0.88, p < 0.01; I² = 76.67%), 0.87 (95% CI: 0.84-0.90, p < 0.01; I² = 90.89%), and 36.63 (95% CI: 25.38-52.87, p < 0.01; I² = 100%), respectively. The optimal cut-off values of TE were 7.25 kPa for diagnosing significant fibrosis and 12.4 kPa for diagnosing cirrhosis, respectively.

CONCLUSION

TE is of great value in the detection of patients with CHB-related cirrhosis but has a suboptimal accuracy in the detection of significant fibrosis.

Liver sampling: a vital window into HBV pathogenesis on the path to functional cure

In order to optimally refine the multiple emerging drug targets for hepatitis B virus (HBV), it is vital to evaluate virological and immunological changes at the site of infection. Traditionally liver biopsy has been the mainstay of HBV disease assessment, but with the emergence of non-invasive markers of liver fibrosis, there has been a move away from tissue sampling. Here we argue that liver biopsy remains an important tool, not only for the clinical assessment of HBV but also for research progress and evaluation of novel agents. The importance of liver sampling has been underscored by recent findings of specialised subsets of tissue-resident immune subsets capable of efficient pathogen surveillance, compartmentalised in the liver and not sampled in the blood. Importantly, the assessment of virological parameters, such as cccDNA quantitation, also requires access to liver tissue. We discuss strategies to maximise information obtained from the site of infection and disease pathology. Fine needle aspirates of the liver may allow longitudinal sampling of the local virus/host landscape. The careful utilisation of liver tissue and aspirates in conjunction with blood will provide critical information in the assessment of new therapeutics for the functional cure of HBV.

Comparison of diagnostic accuracy of magnetic resonance elastography and Fibroscan for detecting liver fibrosis in chronic hepatitis B patients: A systematic review and meta-analysis

Aim

This systematic review and meta-analysis was carried out to compare the diagnostic accuracy of Magnetic resonance elastography (MRE) and Fibroscan for detecting liver fibrosis in Chronic Hepatitis B (CHB) patients.

Methods

The PubMed, the Cochrane Library, and the Web of science databases were searched for studies that evaluated the diagnostic value of MRE and Fibroscan for liver fibrosis in CHB patients until March 1^st 2017. The quality of the included studies was assessed by the revised Quality Assessment for Studies of Diagnostic Accuracy tool (QUADAS-2). Meta-disc 4.1 was used to summary the area under receiver operating characteristics curve (AUROC), sensitivity, specificity, diagnostic odds ratios to assess the accuracy of staging liver fibrosis using MRE and Fibroscan.

Results

A total of nine MRE studies with 1470 patients and fifteen Fibroscan studies with 3641 patients were included in this systematic review. The summary AUROC values using MRE and Fibroscan for detecting significant fibrosis, advanced fibrosis and cirrhosis were 0.981 vs. 0.796(p<0.001), 0.972 vs. 0.893(p<0.001), and 0.972 vs. 0.905 (p<0.001). The pooled sensitivity and specificity using MRE for the diagnosis of significant fibrosis, advanced fibrosis and cirrhosis were 92.8% and 93.7%, 89.6% and 93.2%, 89.5% and 92.0%, respectively. The pooled sensitivity and specificity using Fibroscan for the diagnosis of significant fibrosis, advanced fibrosis and cirrhosis were 71.6% and 81.6%, 79.0% and 84.6%, 80.0% and 86.6%, respectively.

Conclusion

MRE is more accurate than Fibroscan in diagnosing liver fibrosis in CHB patients, especially in diagnosing significant fibrosis and advanced fibrosis.

Algorithm of Golgi protein 73 and liver stiffness accurately diagnoses significant fibrosis in chronic HBV infection

BACKGROUND & AIMS

Serum Golgi protein 73 (GP73) is a potential biomarker for fibrosis assessment. We aimed to develop an algorithm based on GP73 and liver stiffness (LS) for further improvement of accuracy for significant fibrosis in patients with antiviral-naïve chronic hepatitis B virus (HBV) infection.

METHODS

Diagnostic accuracy evaluation of GP73 and development of GP73-LS algorithm was performed in training cohort (n = 267) with an independent cohort (n = 133) for validation.

RESULTS

A stepwise increasing pattern of serum GP73 was observed across fibrosis stages in patients with antiviral-naïve chronic HBV infection. Serum GP73 significantly correlated (rho = 0.48, P < .001) with fibrosis stage and was an independent predictor for the presence of significant fibrosis (OR, 95%CI: 1.02, 1.01-1.03, per increase in 1 ng/mL, P < .001). Both LS (AUROC, 95%CI: 0.82, 0.77-0.87, accuracy: 74.7%) and GP73 (AUROC, 95%CI: 0.76, 0.71-0.82, accuracy: 71.5%) well-predicted significant fibrosis and outperformed APRI (AUROC, 95%CI: 0.69, 0.63-0.76, accuracy: 66%) and FIB-4 (AUROC, 95%CI: 0.66, 0.60-0.73, accuracy: 63.6%). Using GP73-LS algorithm, GP73 < 63 in agreement with LS < 8.5 provided accuracy of 81.7% to excluded significant fibrosis. GP73 ≥ 63 in agreement with LS ≥ 8.5 provided accuracy of 93.3% to confirm significant fibrosis. Almost 64% or 68% of patients in the training or validation cohort could be accurately classified.

CONCLUSIONS

Serum GP73 is a robust biomarker for significant fibrosis diagnosis. GP73-LS algorithm provided better diagnostic accuracy than currently available approaches. More than 60% antiviral naïve CHB patients could use this algorithm without resorting to liver biopsy.

Comparison of 2-D Shear Wave Elastography and Transient Elastography for Assessing Liver Fibrosis in Chronic Hepatitis B

This study compared 2-D shear wave elastography (SWE) and transient elastography (TE) for liver fibrosis staging in patients with chronic hepatitis B (CHB) infection using liver biopsy as the reference standard. Patients with CHB infection who underwent liver biopsy were consecutively included. After exclusions, 257 patients were analyzed. Two-dimensional SWE resulted in a significantly higher rate of reliable measurements (98.1%, 252/257) than TE (93.0%, 239/257) (p = 0.011). Liver stiffness measurements of the two examinations exhibited a strong correlation (r = 0.835, p < 0.001). In patients given a confirmed histologic diagnosis, Spearman's rank coefficients were 0.520 in stage F0 (p < 0.001), 0.684 in stage F1 (p < 0.001), 0.777 in stage F2 (p < 0.001), 0.672 in stage F3 (p < 0.001) and 0.755 in stage F4 (p < 0.001). There were no significant differences between the areas under the receiver operating characteristic (ROC) curves of 2-D SWE and TE for liver fibrosis staging (all p values > 0.05). Two-dimensional SWE had diagnostic accuracy comparable to that of TE for liver fibrosis staging. The measurements that the two techniques provide are not interchangeable.

Non-invasive Diagnostics of Liver Fibrosis

Detecting new units of pathogenesis in the liver fibrosis due to alcoholism, chronic viral Hepatitis B and C, non-alcoholic fatty liver disease (NAFLD), autoimmune, parasitic and metabolic diseases and other, reveals perspective for new non-invasive serum biomarkers. In fibrosis, from the wide variety of markers enzymes, proteins and cytokines are mainly used. While direct biomarkers reflect the stage of fibrosis and fibrinogenesis, indirect markers allow assessment of the general liver functions. The combination of direct and indirect markers increases the diagnostic reliability and therefore these panels and indices are investigated quite intensively in recent years in order to decrease the number of liver biopsies without completely replace it, which is still regarded as the reference method.

American Gastroenterological Association Institute Technical Review on the Role of Elastography in Chronic Liver Diseases

Chronic liver diseases (CLDs), due to chronic hepatitis C; hepatitis B; nonalcoholic fatty liver diseases (NAFLD); and alcoholic liver disease, are a leading cause of morbidity and mortality globally. Early identification of patients with cirrhosis at high risk of progression to liver-related complications may facilitate timely care and improve outcomes. With risks and misclassification associated with invasive tests, such as liver biopsy, noninvasive imaging modalities for liver fibrosis assessment have gained popularity. Therefore, the American Gastroenterological Association prioritized clinical guidelines on the role of elastography in CLDs, focusing on vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). To inform these clinical guidelines, the current technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for diagnostic accuracy studies. This technical review addresses focused questions related to: (1) comparative diagnostic performance of VCTE and MRE relative to nonproprietary, serum-based fibrosis markers for detection of cirrhosis in patients with hepatitis C virus (HCV), hepatitis B virus (HBV), NAFLD, and alcoholic liver diseases; (2) performance of specific VCTE-defined liver stiffness cutoffs as a test replacement strategy (to replace liver biopsy) in making key decisions in the management of patients with CLDs; and (3) performance of specific VCTE-defined liver stiffness cutoffs as a triage test to identify patients with low likelihood of harboring high-risk esophageal varices (EVs) or having clinically significant portal hypertension (for presurgical risk stratification). This technical review does not address performance of other noninvasive modalities for assessing fibrosis (eg, acoustic radiation force pulse imaging or shear wave elastography) or steatosis (controlled attenuation parameter or magnetic resonance imaging-estimated proton density fat fraction).

Fibrosis assessment in patients with chronic hepatitis B virus (HBV) infection

Chronic hepatitis B virus (HBV) infection is a major cause of liver morbidity and mortality worldwide. While a proportion of the 250 million individuals chronically infected with HBV will not come to significant harm or require therapy, many others risk developing complications of the end-stage liver disease such as decompensated cirrhosis and hepatocellular carcinoma (HCC), without intervention. Due to the complex natural history of HBV infection, patients require an expert assessment to interpret biochemistry, viral serology and appropriately stage the disease, and to initiate monitoring and/or therapy where indicated. The detection and quantification of liver fibrosis is a key factor for disease management and prognostication for an individual with HBV. The reliance on invasive liver biopsy to stage disease is diminishing with the advent of robust non-invasive blood- and imaging-based algorithms which can reliably stage disease in many cases. These tests are now incorporated into International guidelines for HBV management and relied upon daily to inform clinical judgement. Both blood- and imaging-based approaches have advantages over liver biopsy, including minimal risks, lower cost, better patient acceptance and speed of results, while disadvantages include lower diagnostic accuracy in intermediate disease stages and variability with co-existing hepatic inflammation or steatosis. This review outlines the methods of fibrosis assessment in chronic HBV infection and focuses on the most commonly used blood- and imaging-based non-invasive tests, reviewing their diagnostic performance and applicability to patient care.

Indocyanine green retention test (ICG-r15) as a noninvasive predictor of portal hypertension in patients with different severity of cirrhosis

BACKGROUND AND AIMS

Portal hypertension is a severe consequence of chronic liver disease, responsible for the main clinical complications of cirrhosis. Measurement of the hepatic venous pressure gradient (HVPG) provides important clinical information, but the procedure is invasive and demands expert skills of the staff.In the present study, we aimed to investigate the relationship between the constant infusion indocyanine green (ICG) clearance, the calculated ICG retention test after 15 min (ICG-r15), and HVPG in patients with different severity of cirrhosis for validation of ICG-r15 as a noninvasive predictor of portal hypertension.

METHODS

A total of 325 patients were studied. During a hemodynamic investigation, the ICG clearance was determined using the constant infusion technique and ICG-r15 was calculated.

RESULTS

Assessment of the diagnostic performance of ICG clearance and ICG-r15 as predictors of HVPG above 10 mmHg was performed by receiver operating characteristic curve analyses.The ICG clearance and ICG-r15 performed well in all three Child classes, with the most significant results among Child class A patients [area under the receiver operating characteristic (AUROC)=0.832] and less significant results in Child class B (AUROC=0.7448) and Child class C patients (AUROC=0.7392). Only six out of 102 patients in Child class C had HVPG of less than 12 mmHg.

CONCLUSION

ICG-r15 can be used as an indirect assessment of significant portal hypertension in compensated cirrhotic patients. ICG-r15 may be suitable as a screening tool for the identification of patients for endoscopy and measurement of HVPG.Further validation of ICG-r15 together with other predictors of portal hypertension and its clinical use is encouraged.

Transient elastography in clinical detection of liver cirrhosis: A systematic review and meta-analysis

BACKGROUND/AIMS

Transient elastography is a noninvasive method for measuring liver fibrosis. This meta-analysis assesses the diagnostic performance of transient elastography of detecting liver cirrhosis in patients with liver disease.

PATIENTS AND METHODS

We searched MEDLINE, Cochrane, EMBASE databases until Jan 31, 2015, using the following search terms: elastography and liver cirrhosis. Included studies assessed patients with a diagnosis of liver cirrhosis, with an index test of transient elastography, and with the reference standard being a histopathological exam by liver biopsy. Sensitivity analysis and assessment of risk of bias and publication bias were performed.

RESULTS

Fifty-seven studies were included in the meta-analysis with a total of 10,504 patients. The pooled estimate for the sensitivity of transient elastography for detecting liver fibrosis was 81% and the specificity was 88%. The imputed diagnostic odds ratio (DOR) was 26.08 and the area under the receiver-operating characteristic (AUROC) curve was 0.931.

CONCLUSION

Our findings indicate that transient elastography shows good sensitivity, specificity and a high accuracy for detecting liver cirrhosis. Transient elastography can be used as an additional method for the clinical diagnosis of liver fibrosis and cirrhosis.

Fibroscan improves the diagnosis sensitivity of liver fibrosis in patients with chronic hepatitis B

The aim of the present study was to investigate the diagnostic accuracy of Fibroscan for liver fibrosis in patients with chronic hepatitis B (CHB) with alanine aminotransferase (ALT) levels <2 times the upper normal limit. A total of 263 consecutive patients with CHB and ALT levels <2 times the upper normal limit were enrolled in the present study. Liver biopsies and liver stiffness measurements (LSM) were conducted. Receiver operating characteristic (ROC) analysis was used to determine the predictive ability of LSM for the development of liver fibrosis in patients with stage S1, S2 and S3 liver fibrosis. Bivariate Spearman rank correlation analysis was performed in order to determine the association between liver stiffness value, which was measured by Fibroscan, and liver fibrosis stage, which was measured by liver biopsy. The liver stiffness value was found to be positively correlated with the liver fibrosis stage (r=0.522, P<0.001) and necroinflammatory activity (r=0.461, P<0.001), which was measured by liver biopsy. The optimal cut-off value in the patients with stage S1, S2 and S3 liver fibrosis was 5.5, 8.0 and 10.95 kPa, respectively. The area under the ROC curve for the prediction of the development of liver fibrosis in these patients was 0.696, 0.911 and 0.923, respectively. The threshold of the optimal cut-off value exhibited a high sensitivity and specificity. The results of the present study suggested that Fibroscan may improve the sensitivity of the diagnosis of liver fibrosis in patients with CHB and ALT levels <2 times the upper normal limit, and that this sensitivity may increase with the progression of liver fibrosis.

Systematic review with meta-analysis: the diagnostic accuracy of transient elastography for the staging of liver fibrosis in patients with chronic hepatitis B

BACKGROUND

Transient elastography is a non-invasive method for staging liver fibrosis. The meta-analysis using the hierarchical models to evaluate the diagnostic accuracy of transient elastography for the staging of liver fibrosis in patients with chronic hepatitis B was rarely reported.

AIM

A meta-analysis using the hierarchical models was performed to assess transient elastography for diagnosing and stage liver fibrosis in patients with chronic hepatitis B.

METHODS

Electronic databases were searched and studies were identified to assess the diagnostic accuracy of transient elastography in CHB patients for staging fibrosis F ≥ 2, F ≥ 3 and F = 4 with liver biopsy as a reference standard. The hierarchical summary receiver operating characteristic curve and the bivariate models were performed to evaluate the diagnostic accuracy of transient elastography, and meta-regression analyses were performed to explore the heterogeneity. The quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the quality of studies.

RESULTS

Twenty-seven studies with a total of 4386 patients were included in the meta-analysis. The summary sensitivity of transient elastography for staging fibrosis F ≥ 2, F ≥ 3 and F = 4 was 0.806 (95% CI, 0.756-0.847), 0.819 (95% CI, 0.748-0.874) and 0.863 (95% CI, 0.818-0.898), respectively, and the summary specificity was 0.824 (95% CI, 0.761-0.873), 0.866 (95% CI, 0.824-0.899) and 0.875 (95% CI, 0.840-0.903), respectively. The corresponding area under the summary receiver operating characteristic curve was 0.88 (95% CI, 0.85-0.91), 0.91 (95% CI, 0.88-0.93) and 0.93 (95% CI, 0.91-0.95), respectively. Meta-regression showed that patient age contributed to heterogeneity.

CONCLUSIONS

Transient elastography performs well to diagnose liver fibrosis in patients with chronic hepatitis B, which may reduce the use of liver biopsy.

Mental Disorders in Chronic Liver Diseases with Viral Etiology

The study of chronic viral hepatitis represents a real challenge for modern medicine. If we also analyze this illness from the point of the mental changes involved, the complexity of the study increases. To the etiological, symptomatological polymorphism, alongside the paraclinical and conduct diagnosis, there may be easily added the multitude of mental disorders. The authors have tried, through this paper, to draw the attention upon the importance of studying certain mental disorders connected to a somatic disease, each and every representing a distinct entity, but which together may reach a remarkable complexity.

Low serum hyaluronic acid levels associated with spontaneous HBsAg clearance

Purpose

The pathophysiological underlying mechanism of spontaneous HBsAg clearance in hepatitis B virus (HBV) infected patients is largely unknown. However, serum hyaluronic acid (sHA) plays a role in liver fibrosis progression and reversely could serve as a potential biomarker for HBsAg clearance. This study investigates whether low sHA is associated with HBsAg loss in non-Asian HBV patients.

Methods

Non-Asian women living in Amsterdam with known chronic HBV infection between 1990–2003 were invited for a single follow-up visit at the Municipal Health Service Amsterdam between September 2011 to May 2012. Serum hyaluronic acid and liver stiffness measurement together with clinical evaluation, biochemical and virologic blood tests were performed.

Results

Of the 160 women, HBsAg loss occurred in 38 (23 %) patients between diagnosis and follow-up. sHA levels were lower in HBsAg negative patients compared to HBsAg positive patients (14.5 [9.4–27.2] ng/mL vs 25.0 [12.3–42.5] ng/mL, p <0.01). A similar distinction in sHA between low and high HBV DNA was noted. sHA had a significant discriminatory ability to differentiate between HBsAg positive and HBsAg negative patients, (AUC 0.65 [95 % CI 0.55–0.75], p < 0.01). In multivariable analysis only sHA level was associated with HBsAg loss (OR 0.4 [0.2–0.9]). Finally, F3-F4 fibrosis (cut-off >8.1 kPa) was diagnosed in 3 % in HBsAg negative patients compared to 10 % in HBsAg positive patients (p = 0.15).

Conclusion

Serum HA levels are lower in patients who experience spontaneous HBsAg loss compared to HBsAg positive patients.

ELF score ≥9.8 indicates advanced hepatic fibrosis and is influenced by age, steatosis and histological activity

BACKGROUND & AIMS

There is increasing need to identify individuals with advanced liver fibrosis, who are at risk of complications such as hepatocellular carcinoma. The commercially available enhanced liver fibrosis (ELF) test provides a non-invasive assessment of fibrosis severity. This study was designed to determine the diagnostic accuracy of the manufacturer's cut-off value (≥9.8) in identifying advanced fibrosis.

METHODS

The relationship between ELF score and fibrosis was examined using serum collected at time of liver biopsy for investigation of liver disease, particularly viral hepatitis. Fibrosis was staged using a modified METAVIR score. If available, liver tissue was recut and stained with Sirius red to determine collagen proportional area (CPA) and subsinusoidal fibrosis (SSF).

RESULTS

Enhanced liver fibrosis score ≥9.8 had a sensitivity of 74.4% and specificity 92.4% for detecting advanced fibrosis. In the whole cohort (n = 329), ELF score was more likely to incorrectly classify individuals if age was ≥45 years and METAVIR inflammatory grade was 2 or 3 (adjusted OR, odds ratio 3.71 and 2.62 respectively). In contrast, ELF score was less likely to misclassify individuals in the presence of steatosis (OR 0.37). Neither SSF nor CPA explained the discordance in ELF score for patients with or without advanced fibrosis.

CONCLUSION

Although ELF score ≥9.8 reliably identifies advanced fibrosis in patients with chronic liver disease, both age and inflammatory activity need to be considered when interpreting the result. Importantly, ELF score performed well in the presence of steatosis and could thus be helpful in the assessment of fatty liver disease.

Vibration-controlled transient elastography: a practical approach to the noninvasive assessment of liver fibrosis

PURPOSE OF REVIEW

Therapeutic advances for hepatitis C and the increasing prevalence on nonalcoholic fatty liver disease are reshaping the diagnostic approach to disease staging in clinical hepatology. Well tolerated, inexpensive and reliable alternatives to liver biopsy are a critical need for clinicians and patients alike.

RECENT FINDINGS

Vibration-controlled transient elastography (VCTE, also known as 'transient elastography') is a robust, point-of-care tool for the noninvasive assessment of liver fibrosis. This tool efficiently prioritizes the treatment for patients with viral hepatitis at risk for advanced liver disease and identifies the subgroups with metabolic or cholestatic liver disease who are at the highest risk. Rather than staging fibrosis, VCTE provides an accurate risk estimate of advanced fibrosis. In addition, it is increasingly recognized that elastography can predict outcomes including hepatic decompensation and mortality. The ideal use of this tool is to perform it in conjunction with a serologic marker of fibrosis to confirm its findings.

SUMMARY

When combined with serologic markers of fibrosis, VCTE allows the vast majority of patients to avoid a liver biopsy.

The value of liver and spleen ADC measurements in the diagnosis and follow up of hepatic fibrosis in chronic liver disease

AIMS

To evaluate the value of spleen and liver apparent diffusion coefficients (ADC) in chronic liver disease patients, with and without hepatocellular carcinoma (HCC), and to investigate the use of diffusion-weighted imaging (DWI) in the diagnosis and follow-up of hepatic fibrosis.

MATERIALS AND METHODS

This study population comprised 68 chronic liver disease patients (Group 1) and 70 healthy volunteers as controls (Group 2). In Group 1, 40 patients had chronic hepatitis-B, 20 had chronic hepatitis-C, 5 had non-alcoholic steatohepatitis and 3 had alcoholic steatohepatitis. Diagnosis of chronic liver disease was made by percutaneous liver biopsy and the degree of fibrosis (stage) was determined using the METAVIR scoring system. HCC diagnosis was made with a lesion biopsy. The patient group was subdivided based on the degree of fibrosis (F1, F2, F3 and F4) and presence of HCC. After patient and control groups underwent b-value 600 s/mm(2) DWI examination, liver and spleen ADC values were mapped and measured. The ADC values of the patient groups (F1, F2, F3, F4; with HCC, without HCC) were compared with each other and with the control group.

RESULTS

Liver ADC values were lower in Group 1 compared to Group 2 (P<0·001). There was a statistically significant difference between the patient and control groups liver right lobe, left lobe and caudate lobe ADC values (P<0·001). Comparing the F1, F2, F3 and F4 groups, there was no statistically significant difference found in terms of ADC values (P>0·05). However, as degree of fibrosis increased there was a reduction in ADC values, though not statistically significant. Comparing the groups with HCC and without HCC, there was no statistically significant difference in ADC values (P>0·05). There was no statistical difference in average spleen ADC values between patient and control groups (P>0·05).

CONCLUSIONS

In chronic liver disease, ADC values were lower. As the degree of liver fibrosis increased, ADC levels decreased, though the relationship between ADC values and fibrosis degree was not statistically significant. Quantitative DWI may help in the diagnosis of fibrosis in chronic liver disease patients, however as it does not show the degree of fibrosis, its use in treatment planning and follow-up is controversial. Spleen DWI measurement is not a sufficient method to diagnose and determine the degree of fibrosis in chronic liver disease patients.