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Brazilian Society of Hepatology and Brazilian College of Radiology practice guidance for the use of elastography in liver diseases. Ann Hepatol 2021; 22:100341. [PMID: 33737252 DOI: 10.1016/j.aohep.2021.100341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
In 2015 the European Association for the Study of Liver Diseases (EASL) and the Asociación Latinoamericana para el Estudio del Hígado (ALEH) published a guideline for the use of non-invasive markers of liver disease. At that time, this guideline focused on the available data regarding ultrasonic-related elastography methods. Since then, much has been published, including new data about XL probe use in transient elastography, magnetic resonance elastography, and non-invasive liver steatosis evaluation. In order to draw evidence-based guidance concerning the use of elastography for non-invasive assessment of fibrosis and steatosis in different chronic liver diseases, the Brazilian Society of Hepatology (SBH) and the Brazilian College of Radiology (CBR) sponsored a single-topic meeting on October 4th, 2019, at São Paulo, Brazil. The aim was to establish specific recommendations regarding the use of imaging-related non-invasive technology to diagnose liver fibrosis and steatosis based on the discussion of evidence-based topics by an organizing committee of experts. It was submitted online to all SBH and CBR members. The present document is the final version of the manuscript that supports the use of this new technology as an alternative to liver biopsy.
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2
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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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3
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Johansen P, Howard D, Bishop R, Moreno SI, Buchholtz K. Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements. PHARMACOECONOMICS 2020; 38:485-497. [PMID: 31919793 DOI: 10.1007/s40273-019-00881-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a severe, typically progressive form of non-alcoholic fatty liver disease (NAFLD). The global prevalence of NASH is increasing, driven partly by the global increase in obesity and type 2 diabetes mellitus (T2DM), such that NASH is now a leading cause of cirrhosis. There is currently an unmet clinical need for efficacious and cost-effective treatments for NASH; no pharmacologic agents have an approved indication for NASH. OBJECTIVE Our objective was to summarise and critically appraise published health economic models of NASH, to evaluate their quality and suitability for use in the assessment of novel treatments for NASH, and to identify knowledge gaps, challenges and opportunities for future modelling. METHODS A systematic literature review was performed using the MEDLINE, Embase, Cochrane Library and EconLit databases to identify published health economic analyses in patients with NAFLD or NASH. Supplementary hand searches of grey literature were also performed. Articles published up to November 2019 were included in the review. Quality assessment of identified studies was also performed. RESULTS A total of 19 articles comprising 16 unique models including either NAFLD as a whole or NASH alone were included in the review. Structurally, most models had a state-transition component; in terms of health states, two different approaches to early disease states were used, modelling either progression through fibrosis stages or NAFLD/NASH-specific health states. Conditions that frequently co-exist with NASH, such as obesity, T2DM and cardiovascular disease were not captured in models identified here. Late-stage complications such as cirrhosis, decompensated cirrhosis and hepatocellular carcinoma were consistently included, but input data (e.g. costs, utilities and transition probabilities) for late-stage complications were frequently sourced from other liver disease areas. The quality of included studies was heterogenous, and only a small proportion of studies reported internal and external validation processes. CONCLUSION The health economic models identified in this review are associated with limitations primarily driven by a lack of NASH-specific data. Identified models also largely overlooked the intricate association between NASH and other conditions, including obesity and T2DM, and did not capture the increased risk of cardiovascular events associated with NASH. High-quality, transparent, validated health economic models of NASH will be required to evaluate the cost effectiveness of treatments currently in development, particularly compounds that may target other non-hepatic outcomes.
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4
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Kadatz M, Klarenbach S, Gill J, Gill JS. Cost-effectiveness of using kidneys from hepatitis C nucleic acid test-positive donors for transplantation in hepatitis C-negative recipients. Am J Transplant 2018; 18:2457-2464. [PMID: 29797402 DOI: 10.1111/ajt.14929] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/12/2018] [Accepted: 04/20/2018] [Indexed: 01/25/2023]
Abstract
Kidneys from deceased donors who are hepatitis C virus (HCV) nucleic acid test positive are infrequently used for transplantation in HCV-negative patients due to concerns about disease transmission. With the development of direct-acting antivirals (DAAs) for HCV, there is now potential to use these kidneys in HCV-negative candidates. However, the high cost of DAAs poses a challenge to adoption of this strategy. We created a Markov model to examine the cost-effectiveness of using deceased donors infected with HCV for kidney transplantation in uninfected waitlist candidates. In the primary analysis, this strategy was cost saving and improved health outcomes compared to remaining on the waitlist for an additional 2 or more years to receive a HCV-negative transplant. The strategy was also cost-effective with an incremental cost-effectiveness ratio of $56 018 per quality-adjusted life year (QALY) from the payer perspective, and $4647 per QALY from the societal perspective, compared to remaining on the waitlist for 1 additional year. The results were consistent in 1-way and probabilistic sensitivity analyses. We conclude that the use of kidneys from deceased donors with HCV infection is likely to lead to improved clinical outcomes at reduced cost for HCV-negative transplant candidates.
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Affiliation(s)
- Matthew Kadatz
- Department of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Scott Klarenbach
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Center for Health Evaluation and Outcomes Science, Vancouver, Canada
| | - John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Center for Health Evaluation and Outcomes Science, Vancouver, Canada
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5
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Erman A, Sathya A, Nam A, Bielecki JM, Feld JJ, Thein HH, Wong WWL, Grootendorst P, Krahn MD. Estimating chronic hepatitis C prognosis using transient elastography-based liver stiffness: A systematic review and meta-analysis. J Viral Hepat 2018; 25:502-513. [PMID: 29239068 DOI: 10.1111/jvh.12846] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/30/2017] [Indexed: 12/13/2022]
Abstract
Chronic hepatitis C (CHC) is a leading cause of hepatic fibrosis and cirrhosis. The level of fibrosis is traditionally established by histology, and prognosis is estimated using fibrosis progression rates (FPRs; annual probability of progressing across histological stages). However, newer noninvasive alternatives are quickly replacing biopsy. One alternative, transient elastography (TE), quantifies fibrosis by measuring liver stiffness (LSM). Given these developments, the purpose of this study was (i) to estimate prognosis in treatment-naïve CHC patients using TE-based liver stiffness progression rates (LSPR) as an alternative to FPRs and (ii) to compare consistency between LSPRs and FPRs. A systematic literature search was performed using multiple databases (January 1990 to February 2016). LSPRs were calculated using either a direct method (given the difference in serial LSMs and time elapsed) or an indirect method given a single LSM and the estimated duration of infection and pooled using random-effects meta-analyses. For validation purposes, FPRs were also estimated. Heterogeneity was explored by random-effects meta-regression. Twenty-seven studies reporting on 39 groups of patients (N = 5874) were identified with 35 groups allowing for indirect and 8 for direct estimation of LSPR. The majority (~58%) of patients were HIV/HCV-coinfected. The estimated time-to-cirrhosis based on TE vs biopsy was 39 and 38 years, respectively. In univariate meta-regressions, male sex and HIV were positively and age at assessment, negatively associated with LSPRs. Noninvasive prognosis of HCV is consistent with FPRs in predicting time-to-cirrhosis, but more longitudinal studies of liver stiffness are needed to obtain refined estimates.
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Affiliation(s)
- A Erman
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada
| | - A Sathya
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - A Nam
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - J M Bielecki
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada
| | - J J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, ON, Canada
| | - H-H Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - W W L Wong
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - P Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - M D Krahn
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Abstract
Liver fibrosis is an important pathological precondition for hepatocellular carcinoma. The degree of hepatic fibrosis is positively correlated with liver cancer. Liver fibrosis is a series of pathological and physiological process related to liver cell necrosis and degeneration after chronic liver injury, which finally leads to extracellular matrix and collagen deposition. The early detection and precise staging of fibrosis and cirrhosis are very important for early diagnosis and timely initiation of appropriate therapeutic regimens. The risk of severe liver fibrosis finally progressing to liver carcinoma is >50%. It is known that biopsy is the gold standard for the diagnosis and staging of liver fibrosis. However, this method has some limitations, such as the potential for pain, sampling variability, and low patient acceptance. Furthermore, the necessity of obtaining a tissue diagnosis of liver fibrosis still remains controversial. An increasing number of reliable non-invasive approaches are now available that are widely applied in clinical practice, mostly in cases of viral hepatitis, resulting in a significantly decreased need for liver biopsy. In fact, the non-invasive detection and evaluation of liver cirrhosis now has good accuracy due to current serum markers, ultrasound imaging, and magnetic resonance imaging quantification techniques. A prominent advantage of the non-invasive detection and assessment of liver fibrosis is that liver fibrosis can be monitored repeatedly and easily in the same patient. Serum biomarkers have the advantages of high applicability (>95%) and good reproducibility. However, their results can be influenced by different patient conditions because none of these markers are liver-specific. The most promising techniques appear to be transient elastography and magnetic resonance elastography because they provide reliable results for the detection of fibrosis in the advanced stages, and future developments promise to increase the reliability and accuracy of the staging of hepatic fibrosis. This article aims to describe the recent progress in the development of non-invasive assessment methods for the staging of liver fibrosis, with a special emphasize on computer-aided quantitative and deep learning methods.
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Affiliation(s)
- Chengxi Li
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Rentao Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Wei Zhang
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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7
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van Katwyk S, Coyle D, Cooper C, Pussegoda K, Cameron C, Skidmore B, Brener S, Moher D, Thavorn K. Transient elastography for the diagnosis of liver fibrosis: a systematic review of economic evaluations. Liver Int 2017; 37:851-861. [PMID: 27699993 DOI: 10.1111/liv.13260] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver biopsy remains the gold standard for the diagnosis of liver fibrosis, but its use as a diagnostic tool is limited by its invasive nature and high cost. OBJECTIVE The aim of this study was to systematically review the cost-effectiveness of transient elastography (TE) with and without controlled attenuation parameter (CAP) for the diagnosis of liver fibrosis or steatosis in patients with hepatitis B, hepatitis C, alcoholic liver disease and non-alcoholic fatty liver disease. METHODS An economic literature search was performed. Eligibility criteria included systematic reviews, health technology assessments or economic evaluations of TE compared to liver biopsy and other non-invasive tests. After abstract screening, full-text reports of potentially relevant articles were assessed in duplicate. The methodological quality of the included studies was also appraised. RESULTS The database search yielded 253 records; four cost-effectiveness and four cost-utility studies were included. The methodological quality of the included studies varies. High-quality cost-effectiveness studies not only suggested that TE is less costly but also less accurate than liver biopsy. The incremental cost-effectiveness ratio (ICER) of TE improves with a greater level of diagnostic accuracy and a higher degree of liver fibrosis. High-quality cost-utility studies indicated that TE is a cost-effective alternative to biopsy with ICER between $9000 and $14 000 per QALY for patients with hepatitis C. We did not find studies that assessed the cost-effectiveness of TE with CAP for the diagnosis of liver steatosis. CONCLUSIONS Transient elastography is an economically attractive alternative to liver biopsy and other non-invasive diagnostic tests especially for patients with a higher degree of liver fibrosis.
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Affiliation(s)
- Sasha van Katwyk
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Doug Coyle
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Health Economics Research Group, Brunel University London, Uxbridge, UK
| | - Curtis Cooper
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Ottawa Hospital and Regional Hepatitis Program, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kusala Pussegoda
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Chris Cameron
- Evidence Synthesis Group, Cornerstone Research Group, Burlington, ON, Canada
| | - Becky Skidmore
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - David Moher
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute of Clinical and Evaluative Sciences (ICES Ottawa), Ottawa, ON, Canada
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8
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Summers JA, Radhakrishnan M, Morris E, Chalkidou A, Rua T, Patel A, McMillan V, Douiri A, Wang Y, Ayis S, Higgins J, Keevil S, Lewis C, Peacock J. Virtual Touch™ Quantification to Diagnose and Monitor Liver Fibrosis in Hepatitis B and Hepatitis C: A NICE Medical Technology Guidance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:139-154. [PMID: 27601240 PMCID: PMC5343083 DOI: 10.1007/s40258-016-0277-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Virtual Touch™ Quantification (VTq) is a software application used with Siemens Acuson ultrasound scanners to assess the stiffness of liver tissue. The National Institute for Health and Care Excellence (NICE) Medical Technologies Advisory Committee (MTAC) selected VTq for evaluation and invited the company to submit clinical and economic evidence. King's Technology Evaluation Centre, an External Assessment Centre (EAC) commissioned by NICE, independently assessed the evidence submitted. The EAC conducted its own systematic review, meta-analysis and economic analysis to supplement the company's submitted evidence. The meta-analyses comparing VTq and transient elastography (TE) with liver biopsy (LB) provided pooled estimates of liver stiffness and stage of fibrosis for the study populations (hepatitis B, hepatitis C or combined populations). When comparing significant fibrosis (Metavir score F ≥ 2) for both hepatitis B and C, VTq had slightly higher values for both sensitivity and specificity (77 and 81 %) than TE (76 and 71 %). The overall prevalence of cirrhosis (F4, combined populations) was similar with VTq and TE (23 vs. 23 %), and significant fibrosis (F ≥ 2) was lower for VTq than for TE (55 vs. 62 %). The EAC revised the company's de novo cost model, which resulted in a cost saving of £53 (against TE) and £434 (against LB). Following public consultation, taking into account submitted comments, NICE Medical Technology Guidance MTG27 was published in September 2015. This recommended the adoption of the VTq software to diagnose and monitor liver fibrosis in patients with hepatitis B or hepatitis C.
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Affiliation(s)
- Jennifer A Summers
- King's Technology Evaluation Centre, London, UK.
- Division of Health and Social Care Research, King's College London, 4th Floor Addison House, Guy's Campus, London, SE1 1UL, UK.
| | - Muralikrishnan Radhakrishnan
- King's Technology Evaluation Centre, London, UK
- King's Health Economics, King's College London, Institute of Psychiatry, The David Goldberg Centre, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - Elizabeth Morris
- King's Technology Evaluation Centre, London, UK
- Division of Imaging Sciences and Biomedical Engineering King's College London, Department of Biomedical Engineering, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Anastasia Chalkidou
- King's Technology Evaluation Centre, London, UK
- Division of Imaging Sciences and Biomedical Engineering King's College London, Department of Biomedical Engineering, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Tiago Rua
- Division of Imaging Sciences and Biomedical Engineering King's College London, Department of Biomedical Engineering, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Anita Patel
- Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Viktoria McMillan
- King's Technology Evaluation Centre, London, UK
- Division of Imaging Sciences and Biomedical Engineering King's College London, Department of Biomedical Engineering, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Abdel Douiri
- Division of Health and Social Care Research, King's College London, 4th Floor Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Yanzhong Wang
- Division of Health and Social Care Research, King's College London, 4th Floor Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Salma Ayis
- Division of Health and Social Care Research, King's College London, 4th Floor Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Joanne Higgins
- Medical Technology Evaluation Programme, National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT, UK
| | - Stephen Keevil
- King's Technology Evaluation Centre, London, UK
- Division of Imaging Sciences and Biomedical Engineering King's College London, Department of Biomedical Engineering, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Department of Medical Physics, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Cornelius Lewis
- King's Technology Evaluation Centre, London, UK
- Department of Medical Engineering and Physics, King's College Hospital, London, SE5 9RS, UK
| | - Janet Peacock
- King's Technology Evaluation Centre, London, UK
- Division of Health and Social Care Research, King's College London, 4th Floor Addison House, Guy's Campus, London, SE1 1UL, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, 7th Floor Capital House, 42 Weston Street, London, SE1 3QD, UK
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9
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Squires JE, Balistreri WF. Hepatitis C virus infection in children and adolescents. Hepatol Commun 2017; 1:87-98. [PMID: 29404447 PMCID: PMC5721428 DOI: 10.1002/hep4.1028] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology, and Nutrition Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center Pittsburgh PA
| | - William F Balistreri
- Division of Gastroenterology Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Cincinnati OH
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10
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Assessing the consistency of liver fibrosis results obtained through biopsy and transient elastography in patients suffering from chronic hepatitis C. Clin Exp Hepatol 2016; 2:109-111. [PMID: 28856272 PMCID: PMC5497419 DOI: 10.5114/ceh.2016.62379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/21/2016] [Indexed: 01/26/2023] Open
Abstract
Until recently, core-needle liver biopsy was used as the gold standard in chronic hepatitis C diagnostics. Information on the inflammatory activity grade and the staging of liver fibrosis or steatosis, obtained through biopsy, constituted an indispensable element in the process of determining patients' eligibility for antiviral treatment. The histological profile of the samples examined was decisive in determining the time for commencing treatment. Given that this procedure involves the risk of complications and temporarily reduces patient living comfort, it was deemed necessary to search for other ways to assess liver fibrosis. Transient elastography is a non-invasive alternative to liver biopsy. The current chronic hepatitis C treatment programme provides the possibility to perform transient elastography instead of liver biopsy. The test result is expressed in kPa. However, liver biopsy is still recommended in certain cases of unclear aetiology, or if discrepancies are found between the elastography results and patient clinical condition. The aim of this study was to compare two methods of liver fibrosis assessment in terms of consistency of results, and to analyse any inconsistent results.
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11
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Li Y, Huang YS, Wang ZZ, Yang ZR, Sun F, Zhan SY, Liu XE, Zhuang H. Systematic review with meta-analysis: the diagnostic accuracy of transient elastography for the staging of liver fibrosis in patients with chronic hepatitis B. Aliment Pharmacol Ther 2016; 43:458-69. [PMID: 26669632 DOI: 10.1111/apt.13488] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 03/02/2015] [Accepted: 11/09/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Y Li
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Y-S Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Z-Z Wang
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Z-R Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - F Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - S-Y Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - X-E Liu
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - H Zhuang
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
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12
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Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach. Interdiscip Perspect Infect Dis 2015; 2015:809289. [PMID: 26779260 PMCID: PMC4686715 DOI: 10.1155/2015/809289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 12/18/2022] Open
Abstract
Liver fibrosis represents the repair mechanism in liver injury and is a feature of most chronic liver diseases. The degree of liver fibrosis in chronic viral hepatitis infections has major clinical implications and presence of advanced fibrosis or cirrhosis determines prognosis. Treatment initiation for viral hepatitis is indicated in most cases of advanced liver fibrosis and diagnosis of cirrhosis entails hepatology evaluation for specialized clinical care. Liver biopsy is an invasive technique and has been the standard of care of fibrosis assessment for years; however, it has several limitations and procedure related complications. Recently, several methods of noninvasive assessment of liver fibrosis have been developed which require either serologic testing or imaging of liver. Imaging based noninvasive techniques are reviewed here and their clinical use is described. Some of the imaging based tests are becoming widely available, and collectively they are shown to be superior to liver biopsy in important aspects. Clinical utilization of these methods requires understanding of performance and quality related parameters which can affect the results and provide wrong assessment of the extent of liver fibrosis. Familiarity with the strengths and weaknesses of each modality is needed to correctly interpret the results in appropriate clinical context.
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Brener S. Transient Elastography for Assessment of Liver Fibrosis and Steatosis: An Evidence-Based Analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2015; 15:1-45. [PMID: 26664664 PMCID: PMC4664937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Liver fibrosis is a sign of advanced liver disease and is often an indication for treatment. The current standard for diagnosing liver fibrosis and steatosis is biopsy, but noninvasive alternatives are available; one of the most common is transient elastography (FibroScan). OBJECTIVES The objective of this analysis was to assess the diagnostic accuracy and clinical utility of transient elastography alone for liver fibrosis and with controlled attenuation parameter (CAP) for steatosis in patients with hepatitis C virus, hepatitis B virus, nonalcoholic fatty liver disease, alcoholic liver disease, or cholestatic diseases. The analysis also aimed to compare the diagnostic accuracy of transient elastography with two alternative noninvasive technologies: FibroTest and acoustic force radiation impulse (ARFI). DATA SOURCES Ovid MEDLINE, Ovid MEDLINE In-Process, Ovid Embase, and all EBM databases were searched for all studies published prior to October 2, 2014. REVIEW METHODS An overview of reviews was conducted using a systematic search and assessment approach. The results of the included systematic reviews were summarized, analyzed, and reported for outcomes related to diagnostic accuracy and clinical utility as a measure of impact on diagnoses, therapeutic decisions, and patient outcomes. RESULTS Fourteen systematic reviews were included, summarizing more than 150 studies. The reviews demonstrated that transient elastography (with or without CAP) has good diagnostic accuracy compared to biopsy for the assessment of liver fibrosis and steatosis. Acoustic force radiation impulse and FibroTest were not superior to transient elastography. LIMITATIONS None of the included systematic reviews reported on the clinical utility of transient elastography. CONCLUSIONS Transient elastography (with or without CAP) offers a noninvasive alternative to biopsy for the assessment of liver fibrosis and steatosis, given its comparable diagnostic accuracy.
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Thavorn K, Coyle D. Transient Elastography and Controlled Attenuation Parameter for Diagnosing Liver Fibrosis and Steatosis in Ontario: An Economic Analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2015; 15:1-58. [PMID: 26664666 PMCID: PMC4664940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Liver fibrosis is characterized by a buildup of connective tissue due to chronic liver damage. Steatosis is the collection of excessive amounts of fat inside liver cells. Liver biopsy remains the gold standard for the diagnosis of liver fibrosis and steatosis, but its use as a diagnostic tool is limited by its invasive nature and high cost. OBJECTIVES To evaluate the cost-effectiveness and budget impact of transient elastography (TE) with and without controlled attenuation parameter (CAP) for the diagnosis of liver fibrosis or steatosis in patients with hepatitis B, hepatitis C, alcoholic liver disease, and nonalcoholic fatty liver disease. DATA SOURCES An economic literature search was performed using computerized databases. For primary economic and budget impact analyses, we obtained data from various sources, such as the Health Quality Ontario evidence-based analysis, published literature, and the Institute for Clinical Evaluative Sciences. REVIEW METHODS A systematic review of existing TE cost-effectiveness studies was conducted, and a primary economic evaluation was undertaken from the perspective of the Ontario Ministry of Health and Long-Term Care. Decision analytic models were used to compare short-term costs and outcomes of TE compared to liver biopsy. Outcomes were expressed as incremental cost per correctly diagnosed cases gained. A budget impact analysis was also conducted. RESULTS We included 10 relevant studies that evaluated the cost-effectiveness of TE compared to other noninvasive tests and to liver biopsy; no cost-effectiveness studies of TE with CAP were identified. All studies showed that TE was less expensive but associated with a decrease in the number of correctly diagnosed cases. TE also improved quality-adjusted life-years in patients with hepatitis B and hepatitis C. Our primary economic analysis suggested that TE led to cost savings but was less effective than liver biopsy in the diagnosis of liver fibrosis. TE became more economically attractive with a higher degree of liver fibrosis. TE with CAP was also less expensive and less accurate than liver biopsy. LIMITATIONS The model did not take into account long-term costs and consequences associated with TE and liver biopsy and did not include costs to patients and their families, or patient preferences related to diagnostic information. CONCLUSIONS TE showed potential cost savings compared to liver biopsy. Further investigation is needed to determine the long-term impacts of TE on morbidity and mortality in Canada and the optimal diagnostic modality for liver fibrosis and steatosis.
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Improving access to transient elastography in Canada will need more than evidence-based guidelines and technical health assessment. Can J Gastroenterol Hepatol 2015; 29:343-4. [PMID: 26466385 PMCID: PMC4610641 DOI: 10.1155/2015/938639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Lepida A, Colombo M, Fernandez I, Abdurakhmanov D, Abrao Ferreira P, Strasser SI, Urbanek P, Mangia A, Calleja JL, Iraqi W, DeMasi R, Lonjon-Domanec I, Moreno C, Wedemeyer H. Final Results of the Telaprevir Access Program: FibroScan Values Predict Safety and Efficacy in Hepatitis C Patients with Advanced Fibrosis or Cirrhosis. PLoS One 2015; 10:e0138503. [PMID: 26398503 PMCID: PMC4580464 DOI: 10.1371/journal.pone.0138503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/29/2015] [Indexed: 12/12/2022] Open
Abstract
Background Liver stiffness determined by transient elastography is correlated with hepatic fibrosis stage and has high accuracy for detecting severe fibrosis and cirrhosis in chronic hepatitis C patients. We evaluated the clinical value of baseline FibroScan values for the prediction of safety and efficacy of telaprevir-based therapy in patients with advanced fibrosis and cirrhosis in the telaprevir Early Access Program HEP3002. Methods 1,772 patients with HCV-1 and bridging fibrosis or cirrhosis were treated with telaprevir plus pegylated interferon-α and ribavirin (PR) for 12 weeks followed by PR alone, the total treatment duration depending on virological response and previous response type. Liver fibrosis stage was determined either by liver biopsy or by non-invasive markers. 1,282 patients (72%) had disease stage assessed by FibroScan; among those 46% were classified as Metavir F3 at baseline and 54% as F4. Results Overall, 1,139 patients (64%) achieved a sustained virological response (SVR) by intention-to-treat analysis. Baseline FibroScan values were tested for association with SVR and the occurrence of adverse events. By univariate analysis, higher baseline FibroScan values were predictive of lower sustained virological response rates and treatment-related anemia. By multivariate analysis, FibroScan was no longer statistically significant as an independent predictor, but higher FibroScan values were correlated with the occurrence of infections and serious adverse events. Conclusions FibroScan has a limited utility as a predictor of safety and efficacy in patients treated with telaprevir-based triple therapy. Nevertheless it can be used in association with other clinical and biological parameters to help determine patients who will benefit from the triple regiments. Trial Registration ClinicalTrials.gov NCT01508286
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Affiliation(s)
- Antonia Lepida
- Liver Unit, Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Massimo Colombo
- Department of Medicine, Division of Gastroenterology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Universita’ degli Studi di Milano, Milan, Italy
| | - Inmaculada Fernandez
- Hospital Universitario 12 de Octubre, Sección de Aparato Digestivo, Madrid, Spain
| | - Djamal Abdurakhmanov
- I.M. Sechenov First Moscow State Medical University, E.M. Tareev Clinic for Nephrology, Internal and Occupational Medicine, Moscow, Russia
| | - Paulo Abrao Ferreira
- Outpatient Clinic to HIV and Viral Hepatitis Division of Infectious Disease, Federal University of São Paulo, São Paulo, Brazil
| | - Simone I. Strasser
- AW Morrow Gastroenterology and Liver Center, Royal Prince Alfred hospital and University of Sydney, Sydney, Australia
| | - Petr Urbanek
- Department of Internal Medicine, First Medical Faculty, Charles University, and Central Military Hospital Prague, Prague, Czech Republic
| | - Alessandra Mangia
- Liver Unit, IRCCS Hospital 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Italy
| | - José L. Calleja
- Gastroenterology, Hospital Universitario Puerta de Hierro, Universidad Autonoma de Madrid, CIBERehd, Madrid, Spain
| | | | - Ralph DeMasi
- Janssen Research and development, Titusville, New Jersey, United States of America
| | | | - Christophe Moreno
- Liver Unit, Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- * E-mail:
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Tapper EB, Sengupta N, Hunink MGM, Afdhal NH, Lai M. Cost-Effective Evaluation of Nonalcoholic Fatty Liver Disease With NAFLD Fibrosis Score and Vibration Controlled Transient Elastography. Am J Gastroenterol 2015; 110:1298-304. [PMID: 26303130 DOI: 10.1038/ajg.2015.241] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/08/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The risk of advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is traditionally assessed with a liver biopsy, which is both costly and associated with adverse events. METHODS We sought to compare the cost-effectiveness of four different strategies to assess fibrosis risk in patients with NAFLD: vibration controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care). We developed a probabilistic decision analytical microsimulation state-transition model wherein we simulated a cohort of 10,000 50-year-old Americans with NAFLD undergoing evaluation by a gastroenterologist. VCTE performance was obtained from a prospective cohort of 144 patients with NAFLD. RESULTS Both the NFS alone and the NFS/VCTE strategies were cost effective at $5,795 and $5,768 per quality-adjusted life years (QALY), respectively. In the microsimulation, the NFS alone and NFS/VCTE strategies were the most cost-effective (dominant) in 66.8 and 33.2% of samples given a willingness-to-pay threshold of $100,000 per QALY. In a sensitivity analysis, the minimum cost per liver biopsy at which the NFS is cost saving is $339 and the maximum cost per VCTE exam at which the NFS/VCTE strategy remains cost saving is $1,593. The expected value of further research on this topic is $526 million. CONCLUSIONS Non-invasive risk stratification with both the NFS alone and the NFS/VCTE are cost-effective strategies for the evaluation and management of patients with NAFLD presenting to a gastroenterologist. Further research is needed to better define the natural history of NAFLD and the effect of novel treatments on decision making.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil Sengupta
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - M G Myriam Hunink
- Departments of Radiology and Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nezam H Afdhal
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Lai
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Zhang E, Wartelle-Bladou C, Lepanto L, Lachaine J, Cloutier G, Tang A. Cost-utility analysis of nonalcoholic steatohepatitis screening. Eur Radiol 2015; 25:3282-94. [PMID: 25994191 DOI: 10.1007/s00330-015-3731-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/23/2015] [Accepted: 03/20/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in Western countries. No studies have examined the cost-effectiveness of screening its advanced form, nonalcoholic steatohepatitis (NASH). METHODS We performed a cost-utility analysis of annual noninvasive screening strategies using third-party payer perspective in a general population in comparison to screening a high-risk obese or diabetic population. Screening algorithms involved well-studied techniques, including NAFLD fibrosis score, transient elastography (TE), and acoustic radiation force impulse (ARFI) imaging for detecting advanced fibrosis (≥ F3); and plasma cytokeratin (CK)-18 for NASH detection. Liver biopsy and magnetic resonance elastography (MRE) were compared as confirmation methods. Canadian dollar (CAD or C$) costs were adjusted for inflation and discounted at 5%. Incremental cost-effectiveness ratio (ICER) of ≤C$ 50,000 was considered cost-effective. RESULTS Compared with no screening, screening with NAFLD fibrosis score/TE/CK-18 algorithm with MRE as confirmation for advanced fibrosis had an ICER of C$ 26,143 per quality-adjusted life year (QALY) gained. Screening in high-risk obese or diabetic populations was more cost-effective, with an ICER of C$ 9,051 and C$ 7,991 per quality-adjusted life-year (QALY) gained, respectively. Liver biopsy confirmation was not found to be cost-effective. CONCLUSIONS Our model suggests that annual NASH screening in high-risk obese or diabetic populations can be cost-effective. KEY POINTS • This cost-utility analysis suggests that screening for nonalcoholic steatohepatitis may be cost-effective. • In particular, screening of high-risk obese or diabetic populations is more cost-effective. • Magnetic resonance elastography was more cost-effective to confirm disease compared to biopsy. • More studies are needed to determine quality of life in nonalcoholic steatohepatitis. • More management strategies for nonalcoholic steatohepatitis are also needed.
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Affiliation(s)
- Eric Zhang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Claire Wartelle-Bladou
- Department of Gastroenterology and Hepatology, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
| | - Luigi Lepanto
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Health Technology Assessment Unit, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
| | - Jean Lachaine
- Faculty of Pharmacy and Pharmacoeconomics, University of Montreal, Montreal, Quebec, Canada
| | - Guy Cloutier
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - An Tang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Saint-Luc Hospital, Montreal, Quebec, Canada.
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada.
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An update on the management of chronic hepatitis C: 2015 Consensus guidelines from the Canadian Association for the Study of the Liver. Can J Gastroenterol Hepatol 2015; 29:19-34. [PMID: 25585348 PMCID: PMC4334064 DOI: 10.1155/2015/692408] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last Canadian consensus conference on the management of chronic hepatitis C, major advances have occurred that warrant a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed and interferon-free, all-oral antiviral regimens have been approved. In light of this new evidence, an update to the 2012 Canadian Association for the Study of the Liver consensus guidelines on the management of hepatitis C was produced. The present document reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved antiviral agents, including those who have previously failed peginterferon and ribavirin-based therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.
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Abstract
INTRODUCTION Assessing the formation and regression of fibrosis in chronic liver disease (CLD) is important. Current methods of assessment employed in clinical practice are inadequate. We present a review of the utility of non-invasive biomarkers of liver fibrosis. SOURCES OF DATA Published material on MEDLINE. AREAS OF AGREEMENT Liver biopsy is an imperfect 'gold standard'. Biomarkers are excellent at detecting significant fibrosis across different aetiologies of CLD. There is growing evidence that they also predict clinical outcomes. AREAS OF CONTROVERSY Non-invasive biomarkers can be used in clinical practice to screen for significant fibrosis, but the utility of liver biopsy is retained in answering specific questions. Biomarkers cannot be used robustly in clinical trials as doubts remain over their ability to detect small changes in fibrosis, inflammation and what influences them. AREAS TIMELY FOR DEVELOPING RESEARCH Community screening and algorithms are being developed with biomarkers to more effectively direct resources. Novel imaging techniques have huge potential advantages, particularly in secondary care for risk stratification.
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Affiliation(s)
- Robert Scott
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, E Floor, West Block QMC, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Indra Neil Guha
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, E Floor, West Block QMC, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Pang JXQ, Zimmer S, Niu S, Crotty P, Tracey J, Pradhan F, Shaheen AAM, Coffin CS, Heitman SJ, Kaplan GG, Swain MG, Myers RP. Liver stiffness by transient elastography predicts liver-related complications and mortality in patients with chronic liver disease. PLoS One 2014; 9:e95776. [PMID: 24755824 PMCID: PMC3995722 DOI: 10.1371/journal.pone.0095776] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/29/2014] [Indexed: 12/18/2022] Open
Abstract
Background Liver stiffness measurement (LSM) by transient elastography (TE, FibroScan) is a validated method for noninvasively staging liver fibrosis. Most hepatic complications occur in patients with advanced fibrosis. Our objective was to determine the ability of LSM by TE to predict hepatic complications and mortality in a large cohort of patients with chronic liver disease. Methods In consecutive adults who underwent LSM by TE between July 2008 and June 2011, we used Cox regression to determine the independent association between liver stiffness and death or hepatic complications (decompensation, hepatocellular carcinoma, and liver transplantation). The performance of LSM to predict complications was determined using the c-statistic. Results Among 2,052 patients (median age 51 years, 65% with hepatitis B or C), 87 patients (4.2%) died or developed a hepatic complication during a median follow-up period of 15.6 months (interquartile range, 11.0–23.5 months). Patients with complications had higher median liver stiffness than those without complications (13.5 vs. 6.0 kPa; P<0.00005). The 2-year incidence rates of death or hepatic complications were 2.6%, 9%, 19%, and 34% in patients with liver stiffness <10, 10–19.9, 20–39.9, and ≥40 kPa, respectively (P<0.00005). After adjustment for potential confounders, liver stiffness by TE was an independent predictor of complications (hazard ratio [HR] 1.05 per kPa; 95% confidence interval [CI] 1.03–1.06). The c-statistic of liver-stiffness for predicting complications was 0.80 (95% CI 0.75–0.85). A liver stiffness below 20 kPa effectively excluded complications (specificity 93%, negative predictive value 97%); however, the positive predictive value of higher results was sub-optimal (20%). Conclusions Liver stiffness by TE accurately predicts the risk of death or hepatic complications in patients with chronic liver disease. TE may facilitate the estimation of prognosis and guide management of these patients.
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Affiliation(s)
- Jack X. Q. Pang
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Scott Zimmer
- Medical Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Sophia Niu
- Medical Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Pam Crotty
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jenna Tracey
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Faruq Pradhan
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abdel Aziz M. Shaheen
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carla S. Coffin
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J. Heitman
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G. Kaplan
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mark G. Swain
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert P. Myers
- Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Poynard T, Vergniol J, Ngo Y, Foucher J, Munteanu M, Merrouche W, Colombo M, Thibault V, Schiff E, Brass CA, Albrecht JK, Rudler M, Deckmyn O, Lebray P, Thabut D, Ratziu V, de Ledinghen V. Staging chronic hepatitis C in seven categories using fibrosis biomarker (FibroTest™) and transient elastography (FibroScan®). J Hepatol 2014; 60:706-14. [PMID: 24291240 DOI: 10.1016/j.jhep.2013.11.016] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 11/15/2013] [Accepted: 11/19/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS FibroTest™ (FT) and Transient Elastography (TE) have been validated as non-invasive markers of METAVIR fibrosis stages from F0 to F4 using biopsy, and as prognostic markers of liver related mortality in patients with chronic hepatitis C. The aim was to extend the validation of FT and TE as markers of critical steps defined by occurrence of cirrhosis without complications (F4.1), esophageal varices (F4.2), and severe complications (F4.3): primary liver cancer, variceal bleeding, or decompensation (ascites, encephalopathy, or jaundice). METHODS The updated individual data of 3927 patients (1046 cirrhotics) without complications at baseline were pooled from three prospective cohorts called "EPIC", "Paris", and "Bordeaux" cohorts. RESULTS At 5 years, among 501 patients without varices at baseline (F4.1) varices occurred in 19 patients [F4.2 incidence of 4.0% (95% CI 2.2-5.8)]. The predictive performance (AUROC) of FT was 0.77 (0.66-0.84; p<0.001). At 10 years severe complications occurred in 203 patients, [F4.3 incidence of 13.4% (9.6-17.1)], including primary liver cancer in 84 patients [6.4% (3.5-9.3)]. FT was predictive (Cox adjusted on treatment) of severe complications [AUROC 0.79 (76-82); p<0.0001], including primary liver cancer [AUROC 0.84 (80-87); p<0.0001]. Similarly TE was predictive of severe complications [AUROC 0.77 (72-81); p<0.0001], including primary liver cancer [AUROC 0.86 (81-90); p<0.0001]. CONCLUSIONS FibroTest™ and TE increase were associated with the occurrence of all severe complications including hepatocellular carcinoma, hepatic insufficiency, and variceal bleeding. FibroTest™ increase was also associated with the occurrence of esophageal varices.
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Affiliation(s)
- Thierry Poynard
- Assistance Publique Hôpitaux de Paris (AP-HP), University Pierre Marie Curie (UPMC), INSERM, UMR_S 938, Liver Center, Paris, France.
| | - Julien Vergniol
- University of Bordeaux, Bordeaux, France; Service de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière (GHPS), AP-HP, Paris, France
| | - Yen Ngo
- BioPredictive, Paris, France
| | - Juliette Foucher
- University of Bordeaux, Bordeaux, France; Service de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière (GHPS), AP-HP, Paris, France
| | | | - Wassil Merrouche
- University of Bordeaux, Bordeaux, France; Service de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière (GHPS), AP-HP, Paris, France
| | - Massimo Colombo
- University of Milano, 1st Division of Gastroenterology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | - Eugene Schiff
- University of Miami Center for Liver Diseases, University of Miami School of Medicine, Miami, FL, USA
| | - Clifford A Brass
- Former employees Merck Sharp & Dohme Corp, Whitehouse Station, NJ, USA
| | - Janice K Albrecht
- Former employees Merck Sharp & Dohme Corp, Whitehouse Station, NJ, USA
| | - Marika Rudler
- Assistance Publique Hôpitaux de Paris (AP-HP), University Pierre Marie Curie (UPMC), INSERM, UMR_S 938, Liver Center, Paris, France
| | | | - Pascal Lebray
- Assistance Publique Hôpitaux de Paris (AP-HP), University Pierre Marie Curie (UPMC), INSERM, UMR_S 938, Liver Center, Paris, France
| | - Dominique Thabut
- Assistance Publique Hôpitaux de Paris (AP-HP), University Pierre Marie Curie (UPMC), INSERM, UMR_S 938, Liver Center, Paris, France
| | - Vlad Ratziu
- Assistance Publique Hôpitaux de Paris (AP-HP), University Pierre Marie Curie (UPMC), INSERM, UMR_S 938, Liver Center, Paris, France
| | - Victor de Ledinghen
- University of Bordeaux, Bordeaux, France; Service de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière (GHPS), AP-HP, Paris, France
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The feasibility and reliability of transient elastography using Fibroscan®: a practice audit of 2335 examinations. Can J Gastroenterol Hepatol 2014; 28:143-9. [PMID: 24619636 PMCID: PMC4071883 DOI: 10.1155/2014/952684] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Liver stiffness measurement (LSM) using transient elastography is widely used in the management of patients with chronic liver disease. OBJECTIVES To examine the feasibility and reliability of LSM, and to identify patient and operator characteristics predictive of poorly reliable results. METHODS The present retrospective study investigated the frequency and determinants of poorly reliable LSM (interquartile range [IQR]⁄median LSM [IQR⁄M] >30% with median liver stiffness ≥7.1 kPa) using the FibroScan (Echosens, France) over a three-year period. Two experienced operators performed all LSMs. Multiple logistic regression analyses examined potential predictors of poorly reliable LSMs including age, sex, liver disease, the operator, operator experience (<500 versus ≥500 scans), FibroScan probe (M versus XL), comorbidities and liver stiffness. In a subset of patients, medical records were reviewed to identify obesity (body mass index ≥30 kg⁄m2). RESULTS Between July 2008 and June 2011, 2335 patients with liver disease underwent LSM (86% using the M probe). LSM failure (no valid measurements) occurred in 1.6% (n=37) and was more common using the XL than the M probe (3.4% versus 1.3%; P=0.01). Excluding LSM failures, poorly reliable LSMs were observed in 4.9% (n=113) of patients. Independent predictors of poorly reliable LSM included older age (OR 1.03 [95% CI 1.01 to 1.05]), chronic pulmonary disease (OR 1.58 [95% CI 1.05 to 2.37), coagulopathy (OR 2.22 [95% CI 1.31 to 3.76) and higher liver stiffness (OR per kPa 1.03 [95% CI 1.02 to 1.05]), including presumed cirrhosis (stiffness ≥12.5 kPa; OR 5.24 [95% CI 3.49 to 7.89]). Sex, diabetes, the underlying liver disease and FibroScan probe were not significant. Although reliability varied according to operator (P<0.0005), operator experience was not significant. In a subanalysis including 434 patients with body mass index data, obesity influenced the rate of poorly reliable results (OR 2.93 [95% CI 0.95 to 9.05]; P=0.06). CONCLUSIONS FibroScan failure and poorly reliable LSM are uncommon. The most important determinants of poorly reliable results are older age, obesity, higher liver stiffness and the operator, the latter emphasizing the need for adequate training.
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