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Kumar M, George R, Vaithiyam V, Sakhuja P, Dahale AS, Dayal A, Dalal A, Sonika U, Sachdeva S, Kumar A. Enhanced Liver Fibrosis Score: Is It Useful for Evaluation of Fibrosis Severity in Chronic Hepatitis C Infection? Cureus 2022; 14:e21168. [PMID: 35165618 PMCID: PMC8831389 DOI: 10.7759/cureus.21168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: The assessment of liver fibrosis is important in patients with chronic hepatitis C (CHC). In recent years, non-invasive tests like enhanced liver fibrosis (ELF) have been developed as an alternative to liver biopsy for estimating the severity of liver fibrosis. Therefore, we aimed to assess whether the ELF score can be used for fibrosis severity estimation using liver biopsy as the gold standard. Materials and methods: Forty-nine patients with CHC were enrolled in this study. Liver biopsy, ELF assessment, and transient elastography (TE) were performed in all patients, and severity of fibrosis on histopathology was assessed by meta-analysis of histological data in viral hepatitis (METAVIR) score. In addition, the diagnostic performance of ELF was evaluated by receiver operator characteristic curve (ROC) analyses, and liver biopsy histopathology was taken as the gold standard for the severity of liver fibrosis. Results: The area under receiver operator characteristic curve (AUROC) for significant fibrosis of ELF score was 0.64 (95% confidence interval {CI}, 0.48-0.79) and of TE was 0.85 (95% CI, 0.73-0.96). The AUROC for advance fibrosis of ELF was 0.77 (95% CI, 0.57-0.97) and TE was 0.98 (95% CI, 0.94-1.0). The calculated cut-offs of ELF overestimated fibrosis in 53.06% (26/49) of patients and underestimated fibrosis in 6.12% (3/49) patients. AUROC of TE was significantly better than ELF for diagnosis of significant fibrosis (p=0.004) and advanced fibrosis (p=0.034). Conclusion: The ELF score can be used for estimating the severity of fibrosis but it is inferior to TE in estimating liver fibrosis severity.
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Guillaume M, Moal V, Delabaudiere C, Zuberbuhler F, Robic MA, Lannes A, Metivier S, Oberti F, Gourdy P, Fouchard-Hubert I, Selves J, Michalak S, Peron JM, Cales P, Bureau C, Boursier J. Direct comparison of the specialised blood fibrosis tests FibroMeter V2G and Enhanced Liver Fibrosis score in patients with non-alcoholic fatty liver disease from tertiary care centres. Aliment Pharmacol Ther 2019; 50:1214-1222. [PMID: 31617224 DOI: 10.1111/apt.15529] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/03/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Enhanced Liver Fibrosis score (ELF) and the FibroMeterV2G are two specialized blood fibrosis tests which include direct markers of liver fibrosis. They have been shown to be more accurate than the simple blood fibrosis tests FIB4 and the non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS). AIMS To directly compare the accuracies of ELF and FibroMeterV2G for the non-invasive diagnosis of liver fibrosis in NAFLD. METHODS Four hundred and seventeen patients with biopsy-proven NAFLD were enrolled from two tertiary care centres. Four blood fibrosis tests were calculated: ELF, FibroMeterV2G , NFS, and FIB4. Advanced fibrosis F3/4 on liver biopsy (NASH CRN scoring) was the primary endpoint. RESULTS Areas under the receiver operating characteristic (AUROC) curve for advanced fibrosis were not significantly different between the direct markers of liver fibrosis (hyaluronate, PIIINP, TIMP-1, alpha2-macroglobulin) and the simple blood fibrosis tests NFS and FIB4. ELF (0.793 ± 0.022) and FibroMeterV2G (0.804 ± 0.021) had significantly higher AUROC than NFS (0.722 ± 0.025, P < .010) and FIB4 (0.739 ± 0.024, P < .020). AUROC for advanced fibrosis and Obuchowski index were not significantly different between ELF and FibroMeterV2G . Algorithms using first ELF or FibroMeterV2G and then liver biopsy in case of undetermined diagnosis provided high diagnostic accuracy for advanced fibrosis: 90% sensitivity, 90% specificity, 93% negative predictive value, 85% positive predictive value, and 90% correct classification. In these algorithms, the rate of liver biopsy was 45.3% with ELF versus 39.3% with FibroMeterV2G (P = .065). CONCLUSIONS ELF and FibroMeterV2G have equal accuracy and perform better than the simple FIB4 and NFS tests for the non-invasive diagnosis of advanced liver fibrosis in patients with NAFLD from tertiary care centres.
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Affiliation(s)
- Maeva Guillaume
- Hepato-Gastroenterology Department, Toulouse University Hospital, Toulouse, France.,Institut CARDIOMET, Fédération Hospitalo-Universitaire IMPACT, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), UMR1048, INSERM/UPS, Toulouse University, Toulouse, France
| | - Valerie Moal
- Biochemistry Department, Angers University Hospital, Angers, France.,HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France
| | | | - Floraine Zuberbuhler
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Marie-Angèle Robic
- Hepato-Gastroenterology Department, Toulouse University Hospital, Toulouse, France
| | - Adrien Lannes
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Sophie Metivier
- Hepato-Gastroenterology Department, Toulouse University Hospital, Toulouse, France
| | - Frederic Oberti
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Pierre Gourdy
- Institut CARDIOMET, Fédération Hospitalo-Universitaire IMPACT, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), UMR1048, INSERM/UPS, Toulouse University, Toulouse, France.,Diabetology Department, Toulouse University Hospital, Toulouse, France
| | - Isabelle Fouchard-Hubert
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Janick Selves
- Pathology Department, Toulouse University Hospital, Toulouse, France
| | - Sophie Michalak
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Pathology Department, Angers University Hospital, Angers, France
| | - Jean-Marie Peron
- Hepato-Gastroenterology Department, Toulouse University Hospital, Toulouse, France
| | - Paul Cales
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | - Christophe Bureau
- Hepato-Gastroenterology Department, Toulouse University Hospital, Toulouse, France
| | - Jerome Boursier
- HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France.,Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
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Dellavance A, Fernandes F, Shimabokuro N, Latini F, Baldo D, Barreto JA, Marvulle V, Andrade LE, Ferraz ML. Enhanced liver fibrosis (ELF) score: Analytical performance and distribution range in a large cohort of blood donors. Clin Chim Acta 2016; 461:151-5. [DOI: 10.1016/j.cca.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 07/21/2016] [Accepted: 08/08/2016] [Indexed: 12/11/2022]
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Tama M, Naylor P, Patel S, Altawil J, Gulati D, Antaki F, Mutchnick MG, Ehrinpreis M. Overestimate of Fibrosis by FIBROSpect® II in African Americans Complicates the Management of their Chronic Hepatitis C. J Clin Transl Hepatol 2016; 4:12-9. [PMID: 27047767 PMCID: PMC4807138 DOI: 10.14218/jcth.2015.00053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 02/02/2016] [Accepted: 02/04/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evaluation of advanced fibrosis in patients with hepatitis C virus (HCV) infection is used to facilitate decisions on treatment strategy and to initiate additional screening measures. Unfortunately, most studies have predominately Caucasian (Cau) patients and may not be as relevant for African Americans (AA). AIMS This study specifically addresses the issue of defining minimal vs. significant fibrosis in African Americans (AA) with chronic hepatitis C (CHC) using noninvasive assays. METHODS All patients (n = 319) seen between 1 January 2008 and 30 June 2013 for whom a FibroSpect II® (FSII) assay was performed and had data for calculation of aspartate aminotransferase (AST) platelet ratio index (APRI) and Fibrosis-4 (FIB-4) were identified using the medical records. RESULTS When liver biopsy score and FSII assay results for the AA patients with CHC were compared, 31% of AA had advanced FSII fibrosis scores (F2-F4) despite a biopsy score of F0-F1. In contrast, 10% of Cau over-scored. The AA false positive rate was 14% for APRI and 34% for FIB-4. Combining FSII with either APRI (7% false positive) or FIB-4 (10% false positive) improved the false positive rate in AA to 7% (FSII + APRI) and 10% (FSII + FIB-4) but reduced the sensitivity for significant fibrosis. CONCLUSIONS The FSII assay overestimates fibrosis in AA and should be used with caution since these patients may not have significant fibrosis. If the APRI or FIB-4 assay is combined with the FSII assay, minimal fibrosis in AA can be defined without subjecting the patients to a subsequent biopsy.
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Affiliation(s)
- Maher Tama
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Paul Naylor
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
- Correspondence to: Paul Naylor, Gastroenterology, 603 Hudson Bldg, Harper University Hospital, 3990 John R, Detroit, MI 48201, USA. Tel: +1-313-745-8601, Fax: +1-313-745-8843, E-mail:
| | - Suhag Patel
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Johnny Altawil
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Dhiraj Gulati
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Fadi Antaki
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Milton G. Mutchnick
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
| | - Murray Ehrinpreis
- Wayne State University School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Detroit, MI, USA
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Stasi C, Milani S. Non-invasive assessment of liver fibrosis: Between prediction/prevention of outcomes and cost-effectiveness. World J Gastroenterol 2016; 22:1711-1720. [PMID: 26819535 PMCID: PMC4722001 DOI: 10.3748/wjg.v22.i4.1711] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/26/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
The assessment of the fibrotic evolution of chronic hepatitis has always been a challenge for the clinical hepatologist. Over the past decade, various non-invasive methods have been proposed to detect the presence of fibrosis, including the elastometric measure of stiffness, panels of clinical and biochemical parameters, and combinations of both methods. The aim of this review is to analyse the most recent data on non-invasive techniques for the evaluation of hepatic fibrosis with particular attention to cost-effectiveness. We searched for relevant studies published in English using the PubMed database from 2009 to the present. A large number of studies have suggested that elastography and serum markers are useful techniques for diagnosing severe fibrosis and cirrhosis and for excluding significant fibrosis in hepatitis C virus patients. In addition, hepatic stiffness may also help to prognosticate treatment response to antiviral therapy. It has also been shown that magnetic resonance elastography has a high accuracy for staging and differentiating liver fibrosis. Finally, studies have shown that non-invasive methods are becoming increasingly precise in either positively identifying or excluding liver fibrosis, thus reducing the need for liver biopsy. However, both serum markers and transient elastography still have “grey area” values of lower accuracy. In this case, liver biopsy is still required to properly assess liver fibrosis. Recently, the guidelines produced by the World Health Organization have suggested that the AST-to-platelet ratio index or FIB-4 test could be utilised for the evaluation of liver fibrosis rather than other, more expensive non-invasive tests, such as elastography or FibroTest.
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Diagnostic usefulness of FibroMeter VCTE for hepatic fibrosis in patients with nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2015; 27:1149-53. [PMID: 26049712 DOI: 10.1097/meg.0000000000000409] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver fibrosis is an important prognostic determinant in patients with nonalcoholic fatty liver disease (NAFLD). The FibroMeter VCTE is a diagnostic tool comprising both biochemical markers and transient elastography (TE) originally developed for the diagnosis of fibrosis in patients with chronic viral hepatitis. In this pilot study, we investigated the diagnostic performance of the FibroMeter VCTE tool for determining fibrosis in patients with biopsy-proven NAFLD. Its diagnostic accuracy was also compared with those of the NAFLD fibrosis score (NFSA) and TE alone. PATIENTS AND METHODS FibroMeter VCTE, NFSA, and TE were determined in 52 patients with NAFLD. The results of liver biopsies were considered the gold standard. Areas under the receiver operating characteristic curve were used to express the diagnostic accuracy of each test. RESULTS Significant (F≥2) and severe (F≥3) fibrosis were detected in 20 (38%) and 10 (19%) patients, respectively. The sensitivity of FibroMeter VCTE, NFSA, and TE for detecting significant fibrosis was 70, 65, and 75%, respectively, whereas specificity was 88, 81, and 78%. The sensitivity of FibroMeter VCTE, NFSA, and TE for diagnosing severe fibrosis was 90, 90, and 100%, respectively, whereas specificity was 93, 78, and 76%. Receiver operating characteristic analysis showed that FibroMeter VCTE had a significantly larger areas under the receiver operating characteristic curve (0.968) compared with both NFSA (0.833, P<0.001) and TE (0.922, P<0.05) for the detection of severe fibrosis. CONCLUSION Our preliminary findings indicate that FibroMeter VCTE is superior to both NFSA and TE for the diagnosis of severe fibrosis in patients with NAFLD.
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Guéchot J. Non-invasive evaluation of liver fibrosis: More well-validated tests available for patient management. Liver Int 2015; 35:1643-5. [PMID: 25619318 DOI: 10.1111/liv.12790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Jérôme Guéchot
- Pôle de Biologie Médicale et Pathologie, site Saint-Antoine, Hôpitaux Universitaires Est Parisien, AP-HP, Paris, France
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Fernandes FF, Ferraz ML, Andrade LE, Dellavance A, Terra C, Pereira G, Pereira JL, Campos F, Figueiredo F, Perez RM. Enhanced liver fibrosis panel as a predictor of liver fibrosis in chronic hepatitis C patients. J Clin Gastroenterol 2015; 49:235-41. [PMID: 24714186 DOI: 10.1097/mcg.0000000000000128] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Evaluation of fibrosis is crucial in the assessment of chronic hepatitis C (CHC). The enhanced liver fibrosis (ELF) is a serological panel including hyaluronic acid (HA), tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), and amino-terminal propeptide of type III procollagen (PIIINP) that has shown good results in predicting liver fibrosis in distinct scenarios of chronic liver diseases. AIMS We aimed to assess the performance of ELF on the detection of fibrosis and cirrhosis in a CHC patient cohort and to compare the results of ELF and transient elastography (TE-Fibroscan) using liver biopsy as reference. PATIENTS AND METHODS One hundred twenty patients were prospectively evaluated by TE and ELF using an ADVIA Centaur automated system. The ELF score was calculated using the manufacturer's algorithm. Biopsies were classified according to the METAVIR score. Receiver operator characteristic curve analyses were performed to evaluate the accuracy of ELF and TE. RESULTS The area under the receiver operator characteristic curve (AUROC) of ELF for the diagnosis of significant fibrosis was 0.81 [95% confidence interval (CI), 0.73-0.87], for advanced fibrosis was 0.82 (95% CI, 0.74-0.88), and for cirrhosis was 0.78 (95% CI, 0.70-0.85). Using the proposed cutoffs, ELF overestimated fibrosis in 66% (81/120) of cases and underestimated in 3% (3/120). We found no statistically significant difference when comparing the AUROC of ELF and TE for diagnosing fibrosis or cirrhosis. CONCLUSIONS ELF panel is a good noninvasive fibrosis marker and showed similar results to TE in CHC patients. However, new cutoff points need to be established to improve its performance on patients with CHC.
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Affiliation(s)
- Flavia F Fernandes
- *Gastroenterology Department, University of the State of Rio de Janeiro †Department of Gastroenterology, Bonsucesso Federal Hospital §D'Or Institute for Research and Education #Internal Medicine Department, Federal University of Rio de Janeiro, Rio de Janeiro ‡Gastroenterology Department, Federal University of São Paulo ∥Rheumatology Division, Universidade Federal de São Paulo, UNIFESP, São Paulo ¶Department of Research and Development, Fleury Group, Brazil
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Xie Q, Zhou X, Huang P, Wei J, Wang W, Zheng S. The performance of enhanced liver fibrosis (ELF) test for the staging of liver fibrosis: a meta-analysis. PLoS One 2014; 9:e92772. [PMID: 24736610 PMCID: PMC3988013 DOI: 10.1371/journal.pone.0092772] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/26/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The enhanced liver fibrosis test (ELF) has been shown to accurately predict significant liver fibrosis in several liver diseases. AIMS To perform a meta-analysis to assess the performance of the ELF test for the assessment of liver fibrosis. STUDY Electronic and manual searches were performed to identify studies of the ELF test. After methodological quality assessment and data extraction, pooled estimates of the sensitivity, specificity, area under the receiver operating characteristic curve (AUROC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and summary receiver operating characteristics (sROC) were assessed systematically. The extent of heterogeneity and reasons for it were assessed. RESULTS Nine studies were identified for analysis. The pooled sensitivity, specificity, positive LR, negative LR, and DOR values of ELF test, for assessment of significant liver fibrosis, were 83% (95% CI=0.80-0.86), 73% (95% CI=0.69-0.77), 4.00 (95% CI=2.50-6.39), 0.24 (95% CI=0.17-0.34), and 16.10 (95% CI=8.27-31.34), respectively; and, for evaluation of severe liver fibrosis, were 78% (95% CI=0.74-0.81), 76% (95% CI=0.73-0.78), 4.39 (95% CI=2.76-6.97), 0.27 (95% CI=0.16-0.46), and 16.01 (95% CI: 7.15-35.82), respectively; and, for estimation of cirrhosis, were 80% (95% CI=0.75-0.85), 71% (95% CI=0.68-0.74), 3.13 (95% CI=2.01-4.87), 0.29 (95% CI=0.19-0.44), and 14.09 (95% CI: 5.43-36.59), respectively. CONCLUSIONS The ELF test shows good performance and considerable diagnostic value for the prediction of histological fibrosis stage.
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Affiliation(s)
- Qingsong Xie
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Xiaohu Zhou
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Pengfei Huang
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Jianfeng Wei
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobilitary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Combined Multi- Organ Transplantation, Ministry of Public Health, Zhejiang Province, Hangzhou, China
- Key laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
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