Application of transient elastography in nonalcoholic fatty liver disease

A Prospective Randomised Comparative Four-arm Intervention Study of Efficacy and Safety of Saroglitazar and Vitamin E in Patients With Non-alcoholic Fatty Liver Disease (NAFLD)/Non-alcoholic Steatohepatitis (NASH)-SVIN TRIAL

Background and aim

Vitamin E is widely prescribed for non-alcoholic steatohepatitis (NASH). Saroglitazar, a novel dual peroxisome proliferator-activator receptor ɑ/γ agonist, is approved in India for non-alcoholic fatty liver disease (NAFLD). No head-to-head comparative study for vitamin E and saroglitazar is available. We studied the efficacy and safety of saroglitazar and vitamin E in NAFLD/NASH.

Materials and methods

We prospectively randomised 175 NAFLD patients into four arms as Saroglitazar 4 mg daily alone (n = 44), vitamin E 800IU daily alone (n = 41), vitamin E and saroglitazar combination (n = 47), and control arm (n = 43). All the baseline variables including liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) were recorded. Reassessment was done after 24 weeks of treatment.

Results

The mean age and body mass index was 45 ± 11 years and 26 ± 3.6 kg/m2, respectively. Compared to control, the decrease in alanine amino transferase levels with saroglitazar, vitamin E, and combination therapy was significant (95% confidence interval [CI]: 6.27-28.25, P = 0.002, 95% CI: -3.39 to 18.88, P = 0.047 and 95% CI: 8.10-29.54, P = 0.001, respectively). The reduction in CAP was significant with saroglitazar and combination therapy (95% CI: -31.94 to 11.99, P = 0.015 and 95% CI: -10.48 to 30.51, P = 0.026, respectively). Only combination therapy shows significant reduction in LSM (95% CI: 0.41-1.68, P = 0.001). Among glycaemic parameters, both saroglitazar alone and combination therapy significantly improved glycosylated haemoglobin levels (P = 0.001 and P = 0.015, respectively), and only combination therapy significantly improved homoeostasis model assessment-estimated insulin resistance (P = 0.047). Saroglitazar alone showed significant reduction in triglyceride and low-density lipoprotein levels (P = 0.038 and P = 0.018, respectively), and combination therapy showed significant increase in high-density lipoprotein levels (P = 0.024).

Conclusions

Combination of Saroglitazar and vitamin E showed statistically significant reduction of LSM and CAP along with biochemical, glycaemic, and lipid parameters.

Clinical trial registry India no

CTRI/2022/01/039538.

Associations between allostatic load and hepatic steatosis and liver fibrosis: evidence from NHANES 2017-2020

BACKGROUND

Allostatic load, the cumulative strain resulting from chronic stress responses, has been linked to disease occurrence and progression, yet research quantifying this relationship is limited. This study aimed to explore the relationship between allostatic load score (ALS) levels and the degree of hepatic steatosis and fibrosis.

METHODS

Data from the National Health and Nutrition Examination Survey 2017-2020 were analyzed. The ALS was based on the statistical distribution, assigning one point for each biomarker if it was in the highest risk quartile, and then summing them to generate the ALS score (range, 0-8). The multivariate linear regression was employed to analyze the association between the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) with ALS. Additionally, multinomial logistic regression was used to investigate the association between ALS and the degree of hepatic steatosis and fibrosis.

RESULTS

Participants had a weighted mean age of 52.69 years and 56.14% were female. In the multivariate linear regression analysis, ALS showed a significant positive correlation with CAP (β = 15.56, 95% CI: 14.50-16.62) and LSM (β = 0.58, 95% CI: 0.48-0.67). Age, healthy dietary level, and PIR had significant interactions with this positive correlation. In the multinomial logistic regression analysis, ALS exhibited a significant positive correlation with different degrees of hepatic steatosis and fibrosis. Consistency of the results was observed in sensitivity analyses using clinical thresholds of ALS.

CONCLUSIONS

Comprehensive clinical assessment targeting load adaptation may enhance the effectiveness of risk assessment in patients with hepatic steatosis and fibrosis.

The associations between fibrosis changes and liver-related events in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

The prognosis of metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with liver fibrosis. We investigated the associations between changes in liver stiffness measurement (LSM) over 3-year period and the development of cirrhosis or hepatocellular carcinoma (HCC) in patients with MASLD.

METHODS

This study involved patients with MASLD who underwent transient elastography at baseline and 3 years after baseline from 2012 to 2020. Low (L), indeterminate (I) and high (H) LSM values were classified as <8 kPa, 8-12 kPa and >12 kPa respectively.

RESULTS

Among 1738 patients, 150 (8.6%) were diagnosed with cirrhosis or HCC. The proportions of patients with L, I and H risk were 69.7%, 19.9% and 10.5% at baseline, and 78.8%, 12.8% and 8.4% at 3 years after baseline, respectively. The incidence rates of cirrhosis or HCC per 1000 person-years were 3.7 (95% confidence interval [CI], 2.4-5.5) in the L → L + I group, 23.9 (95% CI, 17.1-32.6) in the I → L + I group, 38.3 (95% CI, 22.3-61.3) in the H → L + I group, 62.5 (95% CI, 32.3-109.2) in the I → H group, 67.8 (95% CI, 18.5-173.6) in the L → H group and 93.9 (95% CI 70.1-123.1) in the H → H group. Two risk factors for the development of cirrhosis or HCC were LSM changes and low platelet counts.

CONCLUSION

LSM changes could predict clinical outcomes in patients with MASLD. Thus, it is important to monitor changes in the fibrotic burden by regular assessment of LSM values.

Non-alcoholic fatty liver disease in obese subjects as related to increasing insulin resistance and deteriorating glucose control: Three years of follow-up from a longitudinal survey

Purpose

This observational trial was performed to evaluate liver parameters in overweight or obese subjects in the context of insulin resistance and glucose control over time.

Subjects/Methods

Insulin resistance, glucose control and several parameters for liver integrity were monitored in 177 overweight (BMI > 28 kg/m2) subjects over a mean of 30 months. Volunteers were categorized according to insulin resistance (HOMAIR score) and glucose control in subjects with normal glucose control (NGT), impaired glucose control (IGT), or diabetes mellitus type 2 (T2DM). Liver fat and fibrosis were evaluated by sonographic elastography (FibroScan®) and clinical scores, such as the AST/ALT ratio, fatty liver index (FLI), and NAFLD fibrosis score (NFS).

Results

Liver fat fraction as estimated by the controlled attenuation parameter (CAP), and the FLI were significantly higher in subjects with T2DM compared to IGT and NGT. While fasting insulin levels and the HOMAIR score continuously increased over time, no change in CAP or FLI occurred during follow up. CAP was correlated with FLI (r = 0.50; p < 0.0001) and the HOMAIR score (r = 0.32; p < 0.0001). An inverse correlation was observed between serum adiponectin levels and FLI (r = -0.37; p < 0.0001), the HOMAIR score (r = -0.19; p < 0.001, and CAP (r = -0.15; p < 0.01).

Conclusions

In subjects with a BMI ≥ 28 kg/m2, liver fat fraction is significantly elevated in those with T2DM compared to IGT or NGT. Liver fat fraction is associated with deteriorating insulin sensitivity and loss of glucose control. Despite a continuous increase in insulin resistance, no change in liver fat content or stiffness occurred over 30 months.

Exploring the link: magnesium intake and hepatic steatosis in Americans

Purpose

The connection between magnesium and hepatic steatosis has not been well-studied. This study aimed to explore the link between magnesium intake and hepatic steatosis, utilizing data from the National Health and Nutrition Examination Survey (NHANES) 2017-2020.

Materials and methods

The analysis included 5,935 participants, excluding individuals with hepatitis infection or substantial alcohol consumption. Magnesium intake assessment was based on 24-h dietary recalls. Hepatic steatosis evaluation employed the controlled attenuation parameter (CAP), measured via transient elastography. Multivariate regression and subgroup analyses were conducted to scrutinize the relationship between magnesium intake and CAP values.

Results

A higher magnesium intake was associated with lower CAP values, after adjusting for potential confounders. Subgroup analyses indicated an inverted U-shaped correlation between magnesium intake and CAP in women, White people, and non-hypertensive individuals, with respective inflection points at 126, 124.5, and 125 mg/day, respectively. Below these thresholds, a higher magnesium intake correlated with increased CAP values, while above these points, it was associated with decreased CAP.

Conclusion

This extensive population-based study indicates an inverse relationship between magnesium intake and hepatic steatosis in Americans. This relationship displays an inverted U-curve, varying before and after specified inflection points in women, White people, and non-hypertensive individuals. These findings offer insights into tailored magnesium supplementation strategies for preventing and treating liver steatosis, based on gender and ethnicity.

Appendicular Skeletal Muscle Mass to Visceral Fat Area Ratio Predicts Hepatic Morbidities

Background/Aims

: Reports on the association between sarcopenic visceral obesity and non-alcoholic fatty liver disease (NAFLD)-associated morbidities remain scarce. We investigated the association between sarcopenia and visceral obesity, and the influence of this association on hepatic and coronary comorbidities.

Methods

: The appendicular skeletal muscle mass to visceral fat area ratio (SV ratio) was evaluated using bioelectric impedance analysis. NAFLD and significant liver fibrosis were assessed using transient elastography, and high atherosclerotic cardiovascular disease (ASCVD) risk was defined as a 10-year ASCVD risk score >10%. Sarcopenia was defined as appendicular skeletal muscle mass adjusted by body mass index (<0.789 for men and <0.512 for women).

Results

: In total, 82.0% (n=1,205) of the entire study population had NAFLD, and 14.6% of these individuals (n=176) exhibited significant liver fibrosis. Individuals with the lowest SV ratio had a significantly increased risk of NAFLD, significant liver fibrosis, and high ASCVD risk (all p<0.05). Individuals with both the lowest SV ratio and sarcopenia had the highest risk of developing NAFLD (odds ratio [OR]=3.11), significant liver fibrosis (OR=2.03), and high ASCVD risk (OR=4.15), compared with those with a higher SV ratio and without sarcopenia (all p<0.05).

Conclusions

: Low SV ratio combined with sarcopenia was significantly associated with an increased risk of NAFLD, significant liver fibrosis, and high ASCVD risk among individuals with a high risk of NAFLD.

Exploring the association between dietary fiber intake and hepatic steatosis: insights from NHANES

PURPOSE

The link between dietary fiber intake and Non-alcoholic fatty liver disease (NAFLD) is under exploration, yielding inconsistent findings. Considering the limitations of previous research and the significance of dietary fiber in hepatic steatosis, this study investigates the association between dietary fiber intake and Controlled Attenuation Parameter (CAP) among 5935 participants from the National Health and Nutrition Examination Survey (NHANES).

MATERIALS AND METHODS

Multivariable regression was used to evaluate the association between dietary fiber intake and CAP. Smoothed curve fitting and threshold effect analysis techniques were applied to illustrate non-linear relationships.

RESULTS

After adjusting for other variables, a negative correlation emerged between dietary fiber intake and CAP. Subgroup analysis by gender and race/ethnicity revealed a sustained negative association between dietary fiber intake and CAP among females and Whites. Additionally, an inverted U-shaped relationship was observed between dietary fiber intake and CAP among women and other race, with inflection points at 13.80 g/day and 33.45 g/day, respectively.

CONCLUSION

Our research indicates that in the majority of Americans, there is an inverse relationship between dietary fiber intake and hepatic steatosis. This relationship exhibits an inverted U-shaped curve in women and other race, with a threshold effect. The findings of this study hold potential significance for clinical nutrition interventions, personalized dietary guidance, and advancing research into the diet-disease mechanism relationship.

Noninvasive tests for liver fibrosis in 2024: are there different scales for different diseases?

Liver fibrosis is the common pathway from various chronic liver diseases and its progression leads to cirrhosis which carries a significant risk for the development of portal hypertension-related complications and hepatocellular carcinoma. It is crucial to identify and halt the worsening of liver fibrosis given its important prognostic implication. Liver biopsy is the gold standard for assessing the degree of liver fibrosis but is limited due to its invasiveness and impracticality for serial monitoring. Many noninvasive tests have been developed over the years trying to assess liver fibrosis in a practical and accurate way. The tests are mainly laboratory- or imaging-based, or in combination. Laboratory-based tests can be derived from simply routine blood tests to patented laboratory parameters. Imaging modalities include ultrasound and magnetic resonance elastography, in which vibration-controlled transient elastography is the most widely validated and adopted whereas magnetic resonance elastography has been proven the most accurate liver fibrosis assessment tool. Nonetheless, noninvasive tests do not always apply to all liver diseases, nor does a common cut-off value of a test mean the same degree of liver fibrosis in different scenarios. In this review, we discuss the diagnostic and prognostic performance, as well as the confounders and limitations, of different noninvasive tests on liver fibrosis assessment in various liver diseases.

Development of Cost-Effective Fatty Liver Disease Prediction Models in a Chinese Population: Statistical and Machine Learning Approaches

BACKGROUND

The increasing prevalence of nonalcoholic fatty liver disease (NAFLD) in China presents a significant public health concern. Traditional ultrasound, commonly used for fatty liver screening, often lacks the ability to accurately quantify steatosis, leading to insufficient follow-up for patients with moderate-to-severe steatosis. Transient elastography (TE) provides a more quantitative diagnosis of steatosis and fibrosis, closely aligning with biopsy results. Moreover, machine learning (ML) technology holds promise for developing more precise diagnostic models for NAFLD using a variety of laboratory indicators.

OBJECTIVE

This study aims to develop a novel ML-based diagnostic model leveraging TE results for staging hepatic steatosis. The objective was to streamline the model's input features, creating a cost-effective and user-friendly tool to distinguish patients with NAFLD requiring follow-up. This innovative approach merges TE and ML to enhance diagnostic accuracy and efficiency in NAFLD assessment.

METHODS

The study involved a comprehensive analysis of health examination records from Suzhou Municipal Hospital, spanning from March to May 2023. Patient data and questionnaire responses were meticulously inputted into Microsoft Excel 2019, followed by thorough data cleaning and model development using Python 3.7, with libraries scikit-learn and numpy to ensure data accuracy. A cohort comprising 978 residents with complete medical records and TE results was included for analysis. Various classification models, including logistic regression (LR), k-nearest neighbor (KNN), support vector machine (SVM), random forest (RF), light gradient boosting machine (LightGBM), and extreme gradient boosting (XGBoost), were constructed and evaluated based on the area under the receiver operating characteristic curve (AUROC).

RESULTS

Among the 916 patients included in the study, 273 were diagnosed with moderate-to-severe NAFLD. The concordance rate between traditional ultrasound and TE for detecting moderate-to-severe NAFLD was 84.6% (231/273). The AUROC values for the RF, LightGBM, XGBoost, SVM, KNN, and LR models were 0.91, 0.86, 0.83, 0.88, 0.77, and 0.81, respectively. These models achieved accuracy rates of 84%, 81%, 78%, 81%, 76%, and 77%, respectively. Notably, the RF model exhibited the best performance. A simplified RF model was developed with an AUROC of 0.88, featuring 62% sensitivity and 90% specificity. This simplified model used 6 key features: waist circumference, BMI, fasting plasma glucose, uric acid, total bilirubin, and high-sensitivity C-reactive protein. This approach offers a cost-effective and user-friendly tool while streamlining feature acquisition for training purposes.

CONCLUSIONS

The study introduces a groundbreaking, cost-effective ML algorithm that leverages health examination data for identifying moderate-to-severe NAFLD. This model has the potential to significantly impact public health by enabling targeted investigations and interventions for NAFLD. By integrating TE and ML technologies, the study showcases innovative approaches to advancing NAFLD diagnostics.

User Engagement, Acceptability, and Clinical Markers in a Digital Health Program for Nonalcoholic Fatty Liver Disease: Prospective, Single-Arm Feasibility Study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease in the world. Common comorbidities are central obesity, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome. Cardiovascular disease is the most common cause of death among people with NAFLD, and lifestyle changes can improve health outcomes.

OBJECTIVE

This study aims to explore the acceptability of a digital health program in terms of engagement, retention, and user satisfaction in addition to exploring changes in clinical outcomes, such as weight, cardiometabolic risk factors, and health-related quality of life.

METHODS

We conducted a prospective, open-label, single-arm, 12-week study including 38 individuals with either a BMI >30, metabolic syndrome, or type 2 diabetes mellitus and NAFLD screened by FibroScan. An NAFLD-specific digital health program focused on disease education, lowering carbohydrates in the diet, food logging, increasing activity level, reducing stress, and healthy lifestyle coaching was offered to participants. The coach provided weekly feedback on food logs and other in-app activities and opportunities for participants to ask questions. The coaching was active throughout the 12-week intervention period. The primary outcome was feasibility and acceptability of the 12-week program, assessed through patient engagement, retention, and satisfaction with the program. Secondary outcomes included changes in weight, liver fat, body composition, and other cardiometabolic clinical parameters at baseline and 12 weeks.

RESULTS

In total, 38 individuals were included in the study (median age 59.5, IQR 46.3-68.8 years; n=23, 61% female). Overall, 34 (89%) participants completed the program and 29 (76%) were active during the 12-week program period. The median satisfaction score was 6.3 (IQR 5.8-6.7) of 7. Mean weight loss was 3.5 (SD 3.7) kg (P<.001) or 3.2% (SD 3.4%), with a 2.2 (SD 2.7) kg reduction in fat mass (P<.001). Relative liver fat reduction was 19.4% (SD 23.9%). Systolic blood pressure was reduced by 6.0 (SD 13.5) mmHg (P=.009). The median reduction was 0.14 (IQR 0-0.47) mmol/L for triglyceride levels (P=.003), 3.2 (IQR 0.0-5.4) µU/ml for serum insulin (s-insulin) levels (P=.003), and 0.5 (IQR -0.7 to 3.8) mmol/mol for hemoglobin A1c (HbA1c) levels (P=.03). Participants who were highly engaged (ie, who used the app at least 5 days per week) had greater weight loss and liver fat reduction.

CONCLUSIONS

The 12-week-long digital health program was feasible for individuals with NAFLD, receiving high user engagement, retention, and satisfaction. Improved liver-specific and cardiometabolic health was observed, and more engaged participants showed greater improvements. This digital health program could provide a new tool to improve health outcomes in people with NAFLD.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05426382; https://clinicaltrials.gov/study/NCT05426382.

Focused Shear Wave Beam Propagation in Tissue-Mimicking Phantoms

OBJECTIVE

Ultrasound transient elastography (TE) technologies for liver stiffness measurement (LSM) utilize vibration of small, flat pistons, which generate shear waves that lack directivity. The most common cause for LSM failure in practice is insufficient shear wave signal at the needed depths. We propose to increase shear wave amplitude by focusing the waves into a directional beam. Here, we demonstrate the generation and propagation of focused shear wave beams (fSWBs) in gelatin.

METHODS

Directional fSWBs are generated by vibration at 200-400 Hz of a concave piston embedded near the surface of gelatin phantoms and measured with high-frame-rate ultrasound imaging. Five phantoms with a range of stiffnesses are employed. Shear wave speeds assessed by fSWBs are compared with those by radiation-force-based methods (2D SWE). fSWB amplitudes are compared to predictions using an analytical model.

RESULTS

fSWB-derived shear wave speeds are in good agreement with 2D SWE. The amplitudes of fSWBs are localized to the LSM region and are significantly greater than unfocused shear waves. Overall agreement with theory is observed, with some discrepancies in the theoretical source condition.

CONCLUSION

Focusing shear waves can increase the signal in the LSM region for TE. Challenges for translation include coupling piston vibration with the patient skin and increased attenuation in vivo compared to the phantoms employed here.

SIGNIFICANCE

Fibrosis is the most predictive measure of patient outcome in non-alcoholic fatty liver disease. Increased shear wave amplitude in the LSM region can reduce fibrosis assessment failure rates by TE, thus reducing the need for invasive methods like biopsy.

Prevalence of hepatic steatosis and fibrosis in apparently healthy airline pilots: A transient elastography study

Background and Aim

Airline pilots (APs) are often characterized by a sedentary lifestyle, predisposing them to adverse cardiometabolic consequences. In this cross-sectional study, we used transient elastography (TE) to investigate the prevalence of hepatic steatosis and fibrosis among apparently healthy APs.

Materials and Methods

The study cohort consisted of 137 male APs of Caucasian descent who voluntarily underwent TE. To evaluate the extent and severity of hepatic steatosis and fibrosis, we employed established cutoff values for the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

Results

Of the APs, 34 (24.8%) were diagnosed with TE-defined steatosis. Specifically, 25 APs (18.2%) exhibited mild steatosis, 6 (4.4%) moderate steatosis, and 3 (2.2%) severe steatosis. The majority of participants (80 APs or 58.4%) showed no signs of liver fibrosis based on LSM values. However, 49 APs (35.8%) were diagnosed with mild fibrosis (F1), 7 (5.1%) with significant fibrosis (F2), and one (0.7%) with advanced fibrosis (F3). None of the pilots had F4 (cirrhosis). In multivariable linear regression analysis, BMI was the sole independent predictor of both CAP (β=0.34, p<0.001) and LSM (β=0.41, p<0.001) values in our sample of male APs.

Conclusion

TE is a straightforward and convenient non-invasive method for detecting hepatic steatosis and fibrosis in high-risk occupational groups such as APs.

Fibrotic Burden in Patients With Hepatitis B Virus-Related Cirrhosis Is Independently Associated With Poorer Kidney Outcomes

BACKGROUND

We investigated whether higher fibrotic burden was independently associated with poorer kidney outcomes in patients with hepatitis B virus (HBV)-related cirrhosis.

METHODS

A total of 1691 patients with radiologically diagnosed HBV-related cirrhosis but without baseline chronic kidney disease (CKD) who underwent transient elastography (TE) between March 2012 and August 2018 were selected. The study outcome was the composite of development of incident CKD, defined as the occurrence of estimated glomerular filtration rate (eGFR) <60 mL/minute/1.73 m2 or proteinuria (≥1+ on dipstick test) on 2 consecutive measurements during follow-up, 50% decline in eGFR or onset of end-stage kidney disease (initiation of chronic dialysis), or all-cause mortality.

RESULTS

The mean age was 53.4 years and 1030 (60.9%) patients were male. During 8379 person-years of follow-up (median 5.2 years), 60 (3.5%) patients experienced study outcomes. When stratified according to TE-defined fibrotic burden, multivariable Cox models revealed that risk of poorer kidney outcomes was 2.77-fold (95% confidence interval, 1.16-6.63; P < .001) higher in patients with liver stiffness range indicating cirrhosis (≥11.7 kPa), compared to those without significant liver fibrosis (<7.9 kPa). These associations remained significant even after adjusting for vigorous confounders.

CONCLUSIONS

Higher fibrotic burden assessed using TE was independently associated with poorer kidney outcomes in patients with HBV-related cirrhosis.

MAFLD fibrosis score: Using routine measures to identify advanced fibrosis in metabolic-associated fatty liver disease

BACKGROUND

Early screening may prevent fibrosis progression in metabolic-associated fatty liver disease (MAFLD).

AIMS

We developed and validated MAFLD fibrosis score (MFS) for identifying advanced fibrosis (≥F3) among MAFLD patients.

METHODS

This cross-sectional, multicentre study consecutively recruited MAFLD patients receiving tertiary care (Malaysia as training cohort [n = 276] and Hong Kong and Wenzhou as validation cohort [n = 431]). Patients completed liver biopsy, vibration-controlled transient elastography (VCTE), and clinical and laboratory assessment within 1 week. We used machine learning to select 'highly important' predictors of advanced fibrosis, followed by backward stepwise regression to construct MFS formula.

RESULTS

MFS was composed of seven variables: age, body mass index, international normalised ratio, aspartate aminotransferase, gamma-glutamyl transpeptidase, platelet count, and history of type 2 diabetes. MFS demonstrated an area under the receiver-operating characteristic curve of 0.848 [95% CI 0.800-898] and 0.823 [0.760-0.886] in training and validation cohorts, significantly higher than aminotransferase-to-platelet ratio index (0.684 [0.603-0.765], 0.663 [0.588-0.738]), Fibrosis-4 index (0.793 [0.735-0.854], 0.737 [0.660-0.814]), and non-alcoholic fatty liver disease fibrosis score (0.785 [0.731-0.844], 0.750 [0.674-0.827]) (DeLong's test p < 0.05). MFS could include 92.3% of patients using dual cut-offs of 14 and 15, with a correct prediction rate of 90.4%, resulting in a larger number of patients with correct diagnosis compared to other scores. A two-step MFS-VCTE screening algorithm demonstrated positive and negative predictive values and overall diagnostic accuracy of 93.4%, 89.5%, and 93.2%, respectively, with only 4.0% of patients classified into grey zone.

CONCLUSION

MFS outperforms conventional non-invasive scores in predicting advanced fibrosis, contributing to screening in MAFLD patients.

Duration of type 2 diabetes and liver-related events in nonalcoholic fatty liver disease: A landmark analysis

BACKGROUND AND AIMS

We aimed to determine the impact of the duration of type 2 diabetes (T2D) on the risk of liver-related events and all-cause mortality in patients with NAFLD.

APPROACH AND RESULTS

We conducted a territory-wide cohort study of adult patients with NAFLD diagnosed between January 1, 2000, and July 31, 2021, in Hong Kong. T2D was defined by the use of any antidiabetic agents, laboratory tests, and/or diagnosis codes. The primary endpoint was liver-related events, defined as a composite endpoint of HCC and cirrhotic complications. To conduct a more granular assessment of the duration of T2D, we employed landmark analysis in four different ages of interest (biological age of 40, 50, 60, and 70 years). By multivariable analysis with adjustment of non-liver-related deaths, compared with patients without diabetes at age 60 (incidence rate of liver-related events: 0.70 per 1,000 person-years), the adjusted subdistribution HR (SHR) of liver-related events was 2.51 (95% CI: 1.32-4.77; incidence rate: 2.26 per 1,000 person-years) in patients with T2D duration < 5 years, 3.16 (95% CI: 1.59-6.31; incidence rate: 2.54 per 1,000 person-years) in those with T2D duration of 6-10 years, and 6.20 (95% CI: 2.62-14.65; incidence rate: 4.17 per 1000 person-years) in those with T2D duration more than 10 years. A similar association between the duration of T2D and all-cause mortality was also observed.

CONCLUSIONS

Longer duration of T2D is significantly associated with a higher risk of liver-related events and all-cause mortality in patients with NAFLD.

Non-Invasive Diagnostic of NAFLD in Type 2 Diabetes Mellitus and Risk Stratification: Strengths and Limitations

The progressive potential of liver damage in type 2 diabetes mellitus (T2DM) towards advanced fibrosis, end-stage liver disease, and hepatocarcinoma has led to increased concern for quantifying liver injury and individual risk assessment. The combination of blood-based markers and imaging techniques is recommended for the initial evaluation in NAFLD and for regular monitoring to evaluate disease progression. Continued development of ultrasonographic and magnetic resonance imaging methods for accurate quantification of liver steatosis and fibrosis, as well as promising tools for the detection of high-risk NASH, have been noted. In this review, we aim to summarize available evidence regarding the usefulness of non-invasive methods for the assessment of NAFLD in T2DM. We focus on the power and limitations of various methods for diagnosis, risk stratification, and patient monitoring that support their implementation in clinical setting or in research field.

[Use of a controlled attenuation parameter for the diagnosis of non-alcoholic fatty liver disease]

AIM

To evaluate the efficacy of vibration-controlled transient elastography (VCTE) with a controlled attenuation parameter (CAP) in a population of patients with non-alcoholic fatty liver disease (NAFLD)and to compare to US and different non-invasive indices.

MATERIALS AND METHODS

Single center NAFLD patients' database of 2021-2023 years was retrospectively analysed. Data of VCTE evaluation with CAP (FibroScan 530® and FibroScan 630 Expert®) as well as liver US examination results and values of HSI, FLI, BAAT and NAFLD-LFS were extracted. AUROCs for all methods used were constructed and sensitivity and specificity analysis was performed.

RESULTS

The data of 1081 patients were available for analysis (385 with steatosis, 274 with NASH, 422 without NAFLD as a control). Ultrasound examination in the diagnosis of liver steatosis compared to VCTE with CAP showed sensitivity and specificity of 94.6 and 63.7%, respectively. Diagnosis of liver steatosis using indices and scales showed sensitivity and specificity of HSI: 97.9 and 60.1% (AUROC 0.90), FLI: 92.5 and 85.3% (AUROC 0.93), BAAT: 76.6 and 73.5% (AUROC 0.82), NAFLD-LFS: 56.7 and 81.8% (AUROC 0.85).

CONCLUSION

The sensitivity of the US of the liver was consistent with previous studies, but the specificity was low. The HSI index had the best indicators of sensitivity and specificity in relation to the diagnosis of liver steatosis. Combination of liver US and HSI can be used in screening of liver steatosis, however, for the complete diagnosis better tools which can simultaneously evaluate liver steatosis and fibrosis should be used.

Clinical impact of hepatic steatosis on chronic hepatitis B patients in Asia: A systematic review and meta-analysis

Chronic hepatitis B (CHB) and hepatic steatosis (HS) are two prevalent chronic liver diseases in Asia. The incidence of CHB combined with HS is increasing due to the rising obesity rates. However, the impact of HS on CHB remains a topic of debate. Hereby, this meta-analysis aims to examine the effect of HS on Asian patients with CHB. Searches were conducted on four databases to identify articles published from 2005 to 2023. The random-effects or fixed-effects model was used to calculate pooled odds ratios (ORs), weighted mean difference (WMD), and confidence intervals (CIs) for the included articles. Of the 15,959 records screened, 88 studies were included in the analysis of HS prevalence in Asian CHB patients with a prevalence of 36.5% (95% CI: 33.7%-39.3%). In addition, age, sex, body mass index (BMI), waist circumference (WC), alanine aminotransferase (ALT) and combined metabolic diseases have varying degrees of impact on HS in CHB patients. Furthermore, the coexistence of HS was negatively associated with the response to antiviral therapy, including hepatitis B surface antigen (HBeAg) seroconversion (OR = 0.69, 95% CI: 0.53-0.89) and ALT normalization (OR = 0.75, 95% CI: 0.61-0.92) in CHB patients after 48 weeks of treatment. Regarding disease prognosis, HS was not significantly associated with fibrosis or cirrhosis in CHB patients, while an inverse association was observed between HS and hepatocellular carcinoma (HCC) (OR = 2.93, 95% CI: 1.23-6.99). This implies that the coexistence of HS in CHB patients may exacerbate the progression of HCC, which needs to be verified by further studies.

B-mode shear wave elastography can be an alternative method to vibration-controlled transient elastography according to a moderate-scale population study

PURPOSE

We aimed to compare vibration-controlled transient elastography (VCTE) with shear wave elastography (SWE) without previous analysis and generate regression equations between VCTE and new point SWE using combination-elastography.

METHODS

Overall, 829 patients with chronic liver disease were enrolled in this study. Patients with a skin-liver capsule distance > 25 mm were excluded. The reproducibility of VCTE and SWE was confirmed in a phantom study and a clinical study. Considering that combination-elastography allows measurement based on strain elastography, a similar analysis was performed for the liver fibrosis index (LFI), which is a quantitative value for evaluation of liver fibrosis calculated using strain elastography image features. Regression equations between the VCTE and SWE values were obtained based on linear regression analysis.

RESULTS

In the phantom study and clinical study, there was a strong correlation between VCTE and SWE [r = 0.995 (p < 0.001) and r = 0.747 (p < 0.001), respectively). The regression equation between VCTE and SWE was VCTE (kPa) = 1.09 × point SWE (kPa) - 0.17. The Bland-Altman plots revealed no statistically significant bias. Meanwhile, there was no correlation between VCTE and LFI (r = 0.279). There was a statistically significant bias between VCTE and LFI in the Bland-Altman plots. The inter-operator reliability showed a good intraclass correlation coefficient of 0.760 (95% confidence interval: 0.720-0.779).

CONCLUSION

Liver stiffness measured using point SWE was comparable to that measured using VCTE.

Effect of fish oil supplementation on the concentration of miRNA-122, FGF-21 and liver fibrosis in patients with NAFLD: Study protocol for a randomized, double-blind and placebo-controlled clinical trial

BACKGROUND & AIMS

To date, no specific drugs are available for non-alcoholic fatty liver disease (NAFLD), though the effect of fish oil supplementation on improving fibrosis in patients with NAFLD has been evaluated. N-3 polyunsaturated fatty acids (n-3 PUFA) may modulate the concentration of microRNAs (miRNAs) and fibroblast growth factor (FGF)-21, which have been identified as non-invasive markers of liver fibrosis. The present study aims to evaluate whether n-3 PUFA supplementation can modulate miRNA-122 and FGF-21 and improve liver fibrosis and steatosis, measured by transient hepatic elastography (THE), in individuals with NAFLD.

METHODS

A randomized, double-blind, placebo-controlled clinical trial will be conducted to evaluate the effect of 4 g/day supplementation of fish oil (2100 mg EPA and 924 mg DHA) in patients with NAFLD over a 6-month period. Fifty-two patients aged >19 years will be randomly assigned to either a placebo (olive oil) or treatment (fish oil) group. Anthropometric data, food intake, physical activity, body composition, resting energy expenditure (evaluated using indirect calorimetry), liver enzymes, platelets, lipids and glucose profile, inflammatory markers (such as C-reactive protein, neutrophil/lymphocyte, platelet/lymphocyte, and monocyte/lymphocyte ratios), miRNA-122 and FGF-21 concentration, and incorporation of fatty acids into the erythrocyte membrane (analyzed using gas chromatography) as well as the degree of liver fibrosis and steatosis assessed using THE (Fibroscan® Touch 502, Paris, France) and liver biomarkers Steato-Brazilian Longitudinal Study of Adult Health, Fatty Liver Index, NAFLD Fibrosis Score, Fibrosis-4 score, and FibroScan-AST score will be evaluated at the beginning and end of the treatment. Continuous variables with normal distribution will be compared between placebo and intervention groups using Student's T test for independent samples; continuous non-parametric variables will be compared using Dunn or Mann-Whitney test. Associations between categorical variables will be analyzed using the chi-square test, and within-group differences will be evaluated using the Wilcoxon signed-ranks test. The criterion for determining significance will be set at 5%.

CONCLUSION

The present study protocol will investigate the supplementation of EPA-rich fish oil as an alternative treatment for NAFLD and its feasibility in affecting the concentration of miRNA-122 and FGF-21 markers. Its findings will offer valuable contributions to the literature.

REGISTRATION

ReBEC number RBR-8dp876.

Analysis of clinical features and identification of risk factors in patients with non-alcoholic fatty liver disease based on FibroTouch

Our aim was to explore the correlation between ultrasound attenuation parameter (UAP) and liver stiffness measurement (LSM) based on FibroTouch (China) and clinical features in patients with non-alcoholic fatty liver disease (NAFLD), so as to provide a certain basis for the clinical application of FibroTouch in NAFLD. Hepatic steatosis and fibrosis in patients with NAFLD were graded according to FibroTouch, and the relationship between steatosis and fibrosis levels and clinical characteristics was retrospectively analyzed. Hepatic steatosis was positively related with weight, BMI, waist, hyperlipidemia, hyperuricemia, FBG, UA, TG, ALT, AST, GGT, LSM and hepatic fibrosis grading, and was negatively related with gender (male), age and AST/ALT ratio. Hepatic fibrosis was positively related with age, BMI, waist, hypertension, FBG, ALT, AST, GGT, NFS, APRI, FIB-4, UAP and hepatic steatosis grading, and was negatively related with blood platelet (PLT) counts. Moreover, BMI, waist, TG, ALT and LSM were independent risk factors of hepatic steatosis, while decreased PLT counts, AST and UAP were independent risk factors of hepatic fibrosis. Body mass parameters, metabolic risk factors and liver function indicators increase the risk of hepatic steatosis and fibrosis in patients with NAFLD, and UAP and LSM can interact with each other.

Noninvasive risk assessment of hepatic decompensation in patients with hepatitis B virus-related liver cirrhosis

BACKGROUND AND AIM

Hepatic decompensation is a major complication of liver cirrhosis. We validated the predictive performance of the newly proposed CHESS-ALARM model to predict hepatic decompensation in patients with hepatitis B virus (HBV)-related cirrhosis and compared it with other transient elastography (TE)-based models such as liver stiffness-spleen size-to-platelet (LSPS), portal hypertension (PH), varices risk scores, albumin-bilirubin (ALBI), and albumin-bilirubin-fibrosis-4 (ALBI-FIB-4).

METHODS

Four hundred eighty-two patients with HBV-related liver cirrhosis between 2006 and 2014 were recruited. Liver cirrhosis was clinically or morphologically defined. The predictive performance of the models was assessed using a time-dependent area under the curve (tAUC).

RESULTS

During the study period, 48 patients (10.0%) developed hepatic decompensation (median 93 months). The 1-year predictive performance of the LSPS model (tAUC = 0.8405) was higher than those of the PH model (tAUC = 0.8255), ALBI-FIB-4 (tAUC = 0.8168), ALBI (tAUC = 0.8153), CHESS-ALARM (tAUC = 0.8090), and variceal risk score (tAUC = 0.7990). The 3-year predictive performance of the LSPS model (tAUC = 0.8673) was higher than those of the PH risk score (tAUC = 0.8670), CHESS-ALARM (tAUC = 0.8329), variceal risk score (tAUC = 0.8290), ALBI-FIB-4 (tAUC = 0.7730), and ALBI (tAUC = 0.7451). The 5-year predictive performance of the PH risk score (tAUC = 0.8521) was higher than those of the LSPS (tAUC = 0.8465), varices risk score (tAUC = 0.8261), CHESS-ALARM (tAUC = 0.7971), ALBI-FIB-4 (tAUC = 0.7743), and ALBI (tAUC = 0.7541). However, there was no significant difference in the predictive performance among all models at 1, 3, and 5 years (P > 0.05).

CONCLUSIONS

The CHESS-ALARM score was able to reliably predict hepatic decompensation in patients with HBV-related liver cirrhosis and showed similar performance to the LSPS, PH, varices risk scores, ALBI, and ALBI-FIB-4.

Advanced liver fibrosis predicts heart failure and hospitalizations in people with type 2 diabetes: A prospective cohort study from Hong Kong Diabetes Register

AIMS

We aimed to examine the impact of non-alcoholic fatty liver disease (NAFLD) on the clinical outcomes in patients with type 2 diabetes (T2D).

METHODS

Between 2013 and 2014, 1,734 patients with T2D underwent transient elastography (TE) to assess liver status indicated by controlled attenuation parameter (CAP) and liver stiffness measurement (LSM). Liver steatosis was defined by CAP ≥248 dB/m and advanced liver fibrosis by LSM ≥10kPa. In 2019, we assessed their clinical outcomes including hospitalizations and mortality.

RESULTS

In this prospective cohort [56% men, mean (±standard deviation) age:60.8±11.5 years; glycated hemoglobin (HbA_1c)7.8±1.6 %], 798 patients had liver steatosis, 296 patients had advanced liver fibrosis and 640 patients had normal liver at baseline. T2D with advanced liver fibrosis had higher body mass index, waist circumference, waist-hip ratio, fasting plasma glucose, HbA_1c, blood pressure and lipid profiles than their counterparts with NAFLD or normal liver (all p<0.05). After a median follow-up of 6.07 (interquartile range:5.84 to 6.30) years, there were 4,403 incident hospitalizations, 32,119 days of hospital stay, and 171 deaths. Using Cox regression analysis, advanced liver fibrosis was associated with increased risk of heart failure (hazard ratio [95% confidence interval] HR:3.07[1.08-8.68], p=0.035) and hospitalizations (HR: 1.39[1.14 -1.70], p=0.001) while liver steatosis was associated with reduced mortality (HR:0.60[0.41-0.87], p=0.007) compared to their counterparts with normal liver after adjustment for potential confounders.

CONCLUSIONS

T2D comorbid with liver steatosis and advanced liver fibrosis are distinct clinical entities with differences in outcomes. Advanced liver fibrosis is an important predictor for worse outcomes including heart failure and hospitalizations in people with T2D.

Special Population: Lean Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with obesity but around 10% to 20% of patients with NAFLD have normal body mass index, a condition referred to as lean or nonobese NAFLD. Although lean patients more often have milder liver disease, a proportion may nonetheless develop steatohepatitis and advanced liver fibrosis. Both genetic and environmental factors contribute to the development of NAFLD. Noninvasive tests have similarly good accuracy as initial assessments for lean NAFLD. Future studies should determine the most appropriate treatment in this special population.

Metabolic Profile Reflects Stages of Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease worldwide, with fibrosis stage being the main predictor for clinical outcomes. Here, we present the metabolic profile of NAFLD patients with regards to fibrosis progression. We included all consecutive new referrals for NAFLD services between 2011 and 2019. Demographic, anthropometric and clinical features and noninvasive markers of fibrosis were recorded at baseline and at follow-up. Significant and advanced fibrosis were defined using liver stiffness measurement (LSM) as LSM ≥ 8.1 kPa and LSM ≥ 12.1 kPa, respectively. Cirrhosis was diagnosed either histologically or clinically. Fast progressors of fibrosis were defined as those with delta stiffness ≥ 1.03 kPa/year (25% upper quartile of delta stiffness distribution). Targeted and untargeted metabolic profiles were analysed on fasting serum samples using Proton nuclear magnetic resonance (¹H NMR). A total of 189 patients were included in the study; 111 (58.7%) underwent liver biopsy. Overall, 11.1% patients were diagnosed with cirrhosis, while 23.8% were classified as fast progressors. A combination of metabolites and lipoproteins could identify the fast fibrosis progressors (AUROC 0.788, 95% CI: 0.703-0.874, p < 0.001) and performed better than noninvasive markers. Specific metabolic profiles predict fibrosis progression in patients with nonalcoholic fatty liver disease. Algorithms combining metabolites and lipids could be integrated in the risk-stratification of these patients.

Changes in the etiology of chronic liver disease by referral to a FibroScan center: Increasing prevalence of the nonalcoholic fatty liver disease

BACKGROUND AND AIM

Chronic liver disease (CLD) is a leading cause of morbidity and mortality worldwide with a wide etiological spectrum. FibroScan^® is used for follow-up of fibrosis and steatosis. This single-center study aims to review the distribution of indications by referral to FibroScan^®.

MATERIALS AND METHODS

Demographic characteristics, CLD etiologies, and FibroScan^® parameters of the patients who were referred to our tertiary care center between 2013 and 2021 were retrospectively evaluated.

RESULTS

Out of 9345 patients, 4946 (52.93%) were males, and the median age was 48 [18-88] years. Nonalcoholic fatty liver disease (NAFLD) was the most common indication (N=4768, 51.02%), followed by hepatitis B (N=3194, 34.18%) and hepatitis C (N=707, 7.57%). Adjusting for age, sex, and CLD etiology, the results revealed that patients with older age (Odds ratio (OR)=2.908; confidence interval (CI)=2.597-3.256; p<0.001) and patients with hepatitis C (OR=2.582; CI=2.168-3.075; p<0.001), alcoholic liver disease (OR=2.019; CI=1.524-2.674, p<0.001), and autoimmune hepatitis (OR=2.138; CI=1.360-3.660, p<0.001) had increased odds of advanced liver fibrosis compared to NAFLD.

CONCLUSION

NAFLD was the most common indication for referral to FibroScan^®.

Prevalence of at-risk NASH and its association with metabolic syndrome in US adults with NAFLD, 2017-2018

Patients with metabolic syndrome (MetS) have a higher risk for NASH and significant fibrosis. Presence of NASH and advanced fibrosis are associated with adverse outcomes in patients with NAFLD. Using a noninvasive method, we determined the prevalence of at-risk NASH and its association with MetS components in a large population-based analysis. We used the 2017-2018 National Health and Nutrition Examination Survey and included adults ≥18 years with NAFLD (controlled attenuation parameter ≥274 dB/m). Pregnancy, subjects with other causes of liver disease or missing data were excluded. FibroScan-AST (FAST) score was calculated using aspartate aminotransferase, liver stiffness measurement, and controlled attenuation parameter. Patients with a FAST score >0.35 were considered to have at-risk NASH, defined as NASH with NAFLD activity score ≥4 and fibrosis stage ≥2 on liver biopsy. The sample included 687 patients. The overall prevalence of at-risk NASH was 11.6% (95% CI: 8.8-15.1) and was higher in males than females (15.8% vs. 6.5%; p < 0.001). Subjects with comorbidities (diabetes mellitus, obesity, MetS, and insulin resistance) had between 1.3 and 1.7 times higher prevalence than the general population. Among MetS components, elevated glucose/diabetes, large waist circumference, and low HDL were independent risk factors for at risk-NASH. The number of MetS components was also important-one additional component increased the odds of at-risk NASH by 2 times. The FAST score had the highest correlation with alanine aminotransferase (r= 0.70; p < 0.001). We estimated ~9 million people in the US have at-risk NASH and may benefit from active surveillance and therapy.

Pulse-Echo Quantitative US Biomarkers for Liver Steatosis: Toward Technical Standardization

Excessive liver fat (steatosis) is now the most common cause of chronic liver disease worldwide and is an independent risk factor for cirrhosis and associated complications. Accurate and clinically useful diagnosis, risk stratification, prognostication, and therapy monitoring require accurate and reliable biomarker measurement at acceptable cost. This article describes a joint effort by the American Institute of Ultrasound in Medicine (AIUM) and the RSNA Quantitative Imaging Biomarkers Alliance (QIBA) to develop standards for clinical and technical validation of quantitative biomarkers for liver steatosis. The AIUM Liver Fat Quantification Task Force provides clinical guidance, while the RSNA QIBA Pulse-Echo Quantitative Ultrasound Biomarker Committee develops methods to measure biomarkers and reduce biomarker variability. In this article, the authors present the clinical need for quantitative imaging biomarkers of liver steatosis, review the current state of various imaging modalities, and describe the technical state of the art for three key liver steatosis pulse-echo quantitative US biomarkers: attenuation coefficient, backscatter coefficient, and speed of sound. Lastly, a perspective on current challenges and recommendations for clinical translation for each biomarker is offered.

Magnetic resonance imaging improves stratification of fibrosis and steatosis in patients with chronic liver disease

PURPOSE

We aimed to compare the diagnostic accuracy of magnetic resonance imaging (MRI) and transient elastography (TE) in assessing liver fibrosis and steatosis in patients with chronic liver disease (CLD).

METHODS

Patients who underwent liver biopsy or liver surgery at two academic hospitals between 2017 and 2021 were retrospectively recruited. The stages of liver fibrosis and steatosis were evaluated using histologic examination. Liver stiffness (LS) was assessed using MR elastography (LS_MRE) and TE (LS_TE). Liver steatosis was assessed using proton density fat fraction (PDFF) and controlled attenuation parameter (CAP).

RESULTS

The mean age of the study population (n = 280) was 53.6 years and male sex predominated (n = 199, 71.1%). Nonalcoholic fatty liver disease was the most prevalent (n = 127, 45.5%), followed by hepatitis B virus (n = 112, 40.0%). Hepatocellular carcinoma was identified in 130 patients (46.4%). The proportions of F0, F1, F2, F3, and F4 fibrosis were 13.2%, 31.1%, 9.6%, 16.4%, and 29.7%, respectively. LS_MRE had a significantly greater AUROC value than LS_TE for detecting F2-F4 (0.846 vs. 0.781, P = 0.046), whereas LS_MRE and LS_TE similarly predicted F1-4, F3-4, and F4 (all P > 0.05). The proportions of S0, S1, S2, and S3 steatosis were 34.7%, 49.6%, 12.5%, and 3.2%, respectively. PDFF had significantly greater AUROC values than CAP in predicting S1-3 (0.922 vs. 0.806, P < 0.001) and S2-3 (0.924 vs. 0.795, P = 0.005); however, PDFF and CAP similarly predicted S3 (P = 0.086).

CONCLUSION

MRI exhibited significantly higher diagnostic accuracy than TE for detecting significant fibrosis and mild or moderate steatosis in patients with CLD.

The triglyceride glucose-body mass index: a non-invasive index that identifies non-alcoholic fatty liver disease in the general Japanese population

Background

By identifying individuals at high risk for non-alcoholic fatty liver disease (NAFLD), interventional programs could be targeted more effectively. Some studies have demonstrated that triglyceride glucose-body mass index (TyG-BMI) showed an independent positive association with NAFLD. However, research on its diagnostic value in patients with suspected NAFLD is limited. In this study, we aimed to evaluate whether TyG-BMI was accurate in detecting NAFLD in the general Japanese population.

Methods

A cross-sectional study of 14,280 individuals who underwent a comprehensive health examination was conducted. Standard protocols were followed to collect anthropometric measurements, lab data, and ultrasonography features. All participants were randomly stratified into the development group (n = 7118) and validation group (n = 7162). The TyG-BMI was calculated. Following this, the diagnostic value of the TyG-BMI was evaluated based on the area under the receiver-operating characteristic curve (AUROC). Two cutoff points were selected and used to rule out or rule in the NALFD, and the specificity, sensitivity, negative predictive value, and positive predictive value were explored, respectively. In order to verify the stability of the results, external verification was performed.

Results

There were 1272 and 1243 NAFLD participants in the development and validation groups, respectively. The area under the ROC curve (AUC) of TyG-BMI was 0.888 (95% CI 0.876–0.896) and 0.884 (95% CI 0.875–0.894) for the training and validation group, respectively. Using the low TyG-BMI (182.2) cutoff, NAFLD could be excluded with high accuracy (negative predictive value: 96.9% in estimation and 96.9% in validation). The presence of NAFLD could effectively be determined by applying the high cutoff of TyG-BMI (224.0), as the positive predictive value of the estimation and validation groups is 70.7% and 70.1%, respectively. As a result of applying this model, 9996 (70%) of the 14,280 participants would not have undergone ultrasonography, with an accurate prediction of 9308 (93.1%). AUC was 0.874 for external validation using 183,730 Chinese non-obese participants. TyG-BMI was demonstrated to be an excellent diagnostic tool by both internal and external validation.

Conclusions

In conclusion, the present study developed and validated a simple, non-invasive, and cost-effective tool to accurately separate participants with and without NAFLD in the Japanese population, rendering ultrasonography for identifying NAFLD unnecessary in a substantial proportion of people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03611-4.

Association Between Skeletal Muscle Mass and Severity of Steatosis and Fibrosis in Non-alcoholic Fatty Liver Disease

Background

Sarcopenia is known to be the risk factor of non-alcoholic fatty liver disease (NAFLD). However, studies evaluating the association of skeletal muscle mass (SMM) with liver fibrosis by transient elastography are limited. Here, we investigated the association of SMM with hepatic steatosis and fibrosis assessed in Chinese adults.

Methods

Patients who underwent liver ultrasonography at the Health Promotion Center of the First Affiliated Hospital of Nanjing Medical University between January 2020 to June 2021 were enrolled. We used transient elastography to evaluate the degree of hepatic fat and liver stiffness. Appendicular skeletal muscle mass was determined by bioelectrical impedance and was adjusted for body weight to derive the skeletal muscle mass index (SMI).

Results

Of 3,602 finally enrolled individuals, 1,830 had NAFLD and 1,772 did not have NAFLD. SMI gradually decreased as the severity of hepatic steatosis increased (40.47 ± 3.94% vs. 39.89 ± 3.57% vs. 39.22 ± 3.46% vs. 37.81 ± 2.84%, P < 0.001). Individuals with F3-F4 and F2 liver fibrosis groups had significantly lower SMI than individuals with F0-F1 stages (37.51 ± 3.19% vs. 38.06 ± 3.51% vs. 39.36 ± 3.38%, P < 0.001). As the SMI increased, the percentages of subjects with mild and severe NAFLD, and the percentages of subjects in F2 and F3-F4 stage were gradually decreased. SMI was independently associated with the severity of hepatic steatosis and fibrosis by logistic regression analysis. Moreover, decreased SMI was an independent risk factor for NAFLD and fibrosis.

Conclusion

SMI is closely associated with liver fat content and liver fibrosis in Chinese adults with NAFLD.

Comparison of FibroScan-Aspartate Aminotransferase (FAST) Score and Other Non-invasive Surrogates in Predicting High-Risk Non-alcoholic Steatohepatitis Criteria

Identification of non-alcoholic steatohepatitis (NASH) with high activity and fibrosis is a major priority in patients with non-alcoholic fatty liver disease. We validated the predictive value of the FibroScan-aspartate aminotransferase (FAST) score and other non-invasive fibrosis surrogates in predicting high-risk NASH criteria. This multicenter retrospective study recruited 251 biopsy-proven non-alcoholic fatty liver disease (NAFLD) patients (132 [52.6%] men) between 2011 and 2014. The FAST score was calculated using transient elastography data and aspartate aminotransferase (AST) levels. The NAFLD fibrosis score (NFS), fibrosis-4 index (FIB-4), and AST to platelet ratio index (APRI) were calculated using biochemical data. The area under the receiver operating characteristic curves (AUCs) of the FAST score, liver stiffness, NFS, FIB-4, and APRI were 0.752, 0.718, 0.609, 0.650, and 0.722 for NAFLD activity score (NAS) ≥5 (n = 117, 46.6%); 0.788, 0.754, 0.649, 0.701, and 0.747 for fatty liver inhibition of progression-NASH with histologic activity ≥3 (n = 202, 80.5%); 0.807, 0.806, 0.691, 0.732, and 0.760 for severe disease with activity ≥3 and/or fibrosis ≥3 (n = 132, 52.6%); and 0.714, 0.812, 0.748, 0.738, and 0.669 for NASH with NAS ≥4 and fibrosis ≥2 (n = 70, 27.9%), respectively. The FAST score had the highest AUC for the most high-risk NASH criteria, except for in predicting NAS ≥4 and fibrosis ≥2. The liver stiffness value showed consistently acceptable performance in predicting all high-risk NASH criteria. The FAST score has acceptable performance in identifying high-risk NASH. However, liver stiffness alone was not inferior to the FAST score.

Transient Elastography-Assessed Hepatic Steatosis and Fibrosis Are Associated With Body Composition in the United States

BACKGROUND & AIMS

We examined transient elastography assessed hepatic steatosis and fibrosis distributions and relationships with body composition in a representative United States population sample.

METHODS

Liver stiffness and controlled attenuation parameter (CAP) were assessed on 4870 non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic men and women aged 20 years and over in the National Health and Nutrition Examination Survey (NHANES) 2017-2018. Participants underwent anthropometry and dual-energy x-ray absorptiometry (DXA).

RESULTS

Compared to women, men had higher mean CAP (274.2 dB/m vs 254.4 dB/m) and liver stiffness (6.4 kPa vs 5.5 kPa). CAP and liver stiffness increased through middle age and markedly with BMI. In multivariate-adjusted analysis, CAP in the upper quartile was associated with increased age, BMI, waist-to-hip ratio, diabetes, hypertension, alanine aminotransferase (ALT) and C-reactive protein and decreased HDL cholesterol. After adjustment, non-Hispanic Blacks had lower CAP and non-Hispanic Asians had higher CAP. In multivariate-adjusted analysis, liver stiffness in the upper quartile was associated with male sex, increased age, BMI, diabetes, hepatitis C virus positivity, ALT and CAP. Lower stiffness among Non-Hispanic Asians was not significant after adjustment for BMI. DXA trunk and extremity fat mass were positively related to both CAP and liver stiffness with multivariate adjustment (P < .001 for each). Results were similar with CAP and liver stiffness as continuous characteristics.

CONCLUSIONS

In the United States population, increased anthropometric and DXA body composition measures were associated with higher CAP and liver stiffness. Racial-ethnic differences observed merit further research to elucidate the burden of obesity and liver health disparities.

Advanced liver fibrosis measured by transient elastography predicts chronic kidney disease development in individuals with non-alcoholic fatty liver disease

AIMS/HYPOTHESIS

Non-alcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are progressive chronic conditions that share important cardiometabolic risk factors and pathogenic mechanisms. We investigated the association between liver fibrosis measured by transient elastography (TE) and the risk of incident CKD in individuals with NAFLD.

METHODS

A total of 5983 participants with NAFLD (defined as controlled attenuation parameter >222 dB/m) but without CKD who underwent TE between March 2012 and August 2018 were selected. The primary outcome was incident CKD, defined as the occurrence of eGFR <60 ml min^-1 [1.73 m]^-2 or proteinuria (≥1+ on dipstick test) on two consecutive measurements during follow-up. The secondary outcome was a 25% decline in eGFR measured on two consecutive visits.

RESULTS

The mean age was 51.8 years and 3756 (62.8%) participants were male. During 17,801 person-years of follow-up (mean follow-up of 3.0 years), 62 participants (1.0%) developed incident CKD. When stratified into TE-defined fibrosis stages (F0-F4), multivariable Cox models revealed that risk of incident CKD was 5.40-fold (95% CI 2.46, 11.84; p < 0.001) higher in the F3/F4 group (≥9.5 kPa) than in the F0 group (<5.5 kPa). During 17,577 person-years of follow-up (mean follow-up of 3.0 years), 201 participants (3.4%) experienced the secondary outcome, for which the F3/F4 group had a 3.22-fold higher risk (95% CI 1.96, 5.28; p < 0.001) than the F0 group.

CONCLUSIONS/INTERPRETATION

In this large cohort of individuals with NAFLD but without baseline CKD, advanced liver fibrosis measured by TE was significantly associated with a higher risk of incident CKD.

Diagnostic Performance of 2-D Shear Wave Elastography on the Evaluation of Hepatic Fibrosis with Emphasis on Impact of the Different Region-of-Interest Methods

The purpose of this study was to evaluate the impact of the different region-of-interest (ROI) methods of 2-D shear wave elastography (2-D SWE) on hepatic fibrosis diagnosis. In this retrospective study, 83 patients who underwent 2-D SWE with three ROI methods (a circle ROI, a box ROI and multiple ROIs in an elastogram) and transient elastography (TE) were included. Liver stiffness (LS) was measured five times with each ROI method. These LS values were compared, and their correlation with those obtained from TE was evaluated. The LS values obtained using the three different ROI methods differed statistically (p < 0.001). However, the LS values obtained using each ROI method of 2-D SWE were highly correlated with those obtained using TE (r > 0.7, p < 0.001). All three ROI methods of 2-D SWE had high areas under the receiver operating characteristic curve in diagnosing significant fibrosis and cirrhosis (0.841, 0.820 and 0.840, respectively; 0.962, 0.946 and 0.945, respectively). There were no significant differences in area under the receiver operating characteristic curve among the ROI methods of 2-D SWE. Regardless of the ROI method, 2-D SWE had high performance in diagnosing hepatic fibrosis.

Non-invasive tests of non-alcoholic fatty liver disease

ABSTRACT

For the detection of steatosis, quantitative ultrasound imaging techniques have achieved great progress in past years. Magnetic resonance imaging proton density fat fraction is currently the most accurate test to detect hepatic steatosis. Some blood biomarkers correlate with non-alcoholic steatohepatitis, but the accuracy is modest. Regarding liver fibrosis, liver stiffness measurement by transient elastography (TE) has high accuracy and is widely used across the world. Magnetic resonance elastography is marginally better than TE but is limited by its cost and availability. Several blood biomarkers of fibrosis have been used in clinical trials and hold promise for selecting patients for treatment and monitoring treatment response. This article reviews new developments in the non-invasive assessment of non-alcoholic fatty liver disease (NAFLD). Accumulating evidence suggests that various non-invasive tests can be used to diagnose NAFLD, assess its severity, and predict the prognosis. Further studies are needed to determine the role of the tests as monitoring tools. We cannot overemphasize the importance of context in selecting appropriate tests.

Screening for undiagnosed non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH): A population-based risk factor assessment using vibration controlled transient elastography (VCTE)

The screening for undiagnosed non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (SUNN) study was a population-based screening study that aimed to provide proof of concept to encourage community-level screening and detection for this non-communicable disease. Current screening guidelines do not recommend the routine screening of nonalcoholic fatty liver disease (NAFLD) for asymptomatic populations, so providers are not encouraged to actively seek disease, even in high-risk patients. This study sought to determine whether a self-selecting cohort of asymptomatic individuals would have scores based on vibration controlled transient elastography (VCTE) and controlled attenuation parameter (CAP) significantly correlated to risk factors to suggest that routine screening for high-risk patients should be recommended. The study recruited 1,070 self-selected participants in Houston and Galveston County, Texas, 940 of which were included in final analysis. A pre-screening survey was used to determine eligibility. VCTE-based scores analyzed steatosis and fibrosis levels. Fifty-seven percent of the study population demonstrated steatosis without fibrosis, suggesting NAFLD, while 16% demonstrated both steatosis and fibrosis, suggesting NASH. Statistically significant risk factors included factors related to metabolic syndrome, race, and age, while statistically significant protective factors included consumption of certain foods and exercise. The findings of this study suggest that high-risk individuals should be screened for NAFLD even in the absence of symptoms and that community-based screenings are an effective tool, particularly in the absence of proactive guidelines for providers.

Cross-talk between non-alcoholic fatty liver disease and cardiovascular disease: Implications for future trial design

The natural history of non-alcoholic fatty liver disease (NAFLD) is still not fully elucidated. Patients with NAFLD have a low risk of liver complications, unless substantial liver fibrosis has developed. On the other hand, NAFLD has been linked with excess metabolic and cardiovascular complications. Therapies targeting common pathways may benefit both NAFLD and underlying cardiometabolic risk. Therefore, there is a rationale for considering cardiovascular endpoints in the context of NAFLD trials and, vice-versa, to consider the concomitant presence of NAFLD in drug development for cardiometabolic disorders. This manuscript provides a framework for consideration for future trials examining the inter-relationship between cardiovascular disease and NAFLD.

Liver Stiffness-Based Risk Prediction Model for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is associated with an increased hepatocellular carcinoma (HCC) risk. We established and validated a liver stiffness (LS)-based risk prediction model for HCC development in patients with NAFLD. A total of 2666 and 467 patients with NAFLD were recruited in the training and validation cohorts, respectively. NAFLD was defined as controlled attenuated parameter ≥238 dB/m by transient elastography. Over a median of 64.6 months, HCC developed in 22 (0.8%) subjects in the training cohort. Subjects who developed HCC were older and had higher prevalence of diabetes and cirrhosis, lower platelet count, and higher AST levels compared to those who did not develop HCC (all p < 0.05). In multivariate analysis, age ≥60 years (hazard ratio (HR) = 9.1), platelet count <150 × 10³/μL (HR = 3.7), and LS ≥9.3 kPa (HR = 13.8) were independent predictors (all p < 0.05) that were used to develop a risk prediction model for HCC development, together with AST ≥34 IU/L. AUCs for predicting HCC development at 2, 3, and 5 years were 0.948, 0.947, and 0.939, respectively. This model was validated in the validation cohort (AUC 0.777, 0.781, and 0.784 at 2, 3, and 5 years, respectively). The new risk prediction model for NAFLD-related HCC development showed acceptable performance in the training and validation cohorts.

Current and Emerging Biomarkers and Imaging Modalities for Nonalcoholic Fatty Liver Disease: Clinical and Research Applications

PURPOSE

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder that frequently coexists with obesity, metabolic syndrome, and type 2 diabetes. The NAFLD spectrum, ranging from hepatic steatosis to nonalcoholic steatohepatitis, fibrosis, and cirrhosis, can be associated with long-term hepatic (hepatic decompensation and hepatocellular carcinoma) and extrahepatic complications. Diagnosis of NAFLD requires detection of liver steatosis with exclusion of other causes of chronic liver disease. Screening for NAFLD and identification of individuals at risk of end-stage liver disease represent substantial challenges that have yet to be met. NAFLD affects up to 25% of adults, yet only a small proportion will progress beyond steatosis to develop advanced disease (steatohepatitis and fibrosis) associated with increased morbidity and mortality. Identification of this cohort has required the gold standard liver biopsy, which is both invasive and expensive. The use of serum biomarkers and noninvasive imaging techniques is an area of significant clinical relevance. This narrative review outlines current and emerging technologies for the diagnosis of NAFLD, nonalcoholic steatohepatitis, and hepatic fibrosis.

METHODS

We reviewed the literature using PubMed and reviewed national and international guidelines and conference proceedings to provide a comprehensive overview of the evidence.

FINDINGS

Significant advances have been made during the past 2 decades that have enhanced noninvasive assessment of NAFLD without the need for liver biopsy. For the detection of steatosis, abdominal ultrasonography remains the first-line investigation, although a controlled attenuation parameter using transient elastography is more sensitive. For detecting fibrosis, noninvasive serum markers of fibrosis and algorithms based on routine biochemistry are available, in addition to transient elastography. These techniques are well validated and have been incorporated into national and international screening guidelines. These approaches have facilitated more judicious use of liver biopsy but are yet to entirely replace it. Although serum biomarkers present a pragmatic and widely available screening approach for NAFLD in large population-based studies, magnetic resonance imaging techniques offer the benefit of achieving high degrees of accuracy in disease grading, tumor staging, and assessing therapeutic response.

IMPLICATIONS

This diagnostic clinical and research field is rapidly evolving; increasingly combined applications of biomarkers and transient elastography or imaging of selective (intermediate or high risk) cases are being used for clinical and research purposes. Liver biopsy remains the gold standard investigation, particularly in the context of clinical trials, but noninvasive options are emerging, using multimodality assessment, that are quicker, more tolerable, more widely available and have greater patient acceptability.

The Need for Alternatives to Liver Biopsies: Non-Invasive Analytics and Diagnostics

Histology remains essential for the diagnosis and management of many disorders affecting the liver. However, the biopsy procedure itself is associated with a low risk of harm to the patient and cost to the health services; samples may not be adequate and are subject to sampling variation. Furthermore, interpretation often depends on the skill of the pathologist. Increasingly, new techniques are becoming available that are altering the indications for liver biopsy. Many diseases of the liver can be diagnosed and managed using serological and radiological techniques; the degree of fibrosis and fat can often be assessed by serological or imaging techniques and the nature of space occupying lesions defined by serology, imaging and use of liquid biopsy. However, these techniques, too, are subject to limitations: sensitivity and specificity is not always adequate for diagnosis or management; some techniques are expensive and often also require expert interpretation. Although there may be less need for liver biopsy today, histology remains the gold standard as well as an essential tool for the diagnosis and management of many conditions, especially where there are multiple pathologies, or where a diagnosis cannot or has not been made by alternative approaches. Until less invasive techniques become more reliable and accessible, liver histology will remain a key investigation.

Controlled attenuation parameter measured using transient elastography for the noninvasive assessment of macrovesicular steatosis in potential living liver donors

PURPOSE

This study aimed to determine the diagnostic performance of the controlled attenuation parameter (CAP) measured using transient elastography (TE) for assessing macrovesicular steatosis (MaS) in potential living liver donors using same-day biopsy as a reference standard.

METHODS

This retrospective study included 204 living liver donor candidates who underwent TE and liver biopsy on the same day between July 2013 and June 2014. The histologic degree of MaS was determined. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of CAP for diagnosing MaS of >10%, and the optimal cutoff value was identified using the maximal Youden index.

RESULTS

Based on liver biopsy, 185 subjects had MaS of ≤10% and 19 had MaS of >10%. The CAP value was significantly correlated with the percentage of MaS on liver biopsy (r=0.635, P<0.001), and the median CAP value was significantly higher in subjects with MaS of >10% than in those with MaS of ≤10% (300 dB/m vs. 209 dB/m, P<0.001). The AUROC for diagnosing MaS of >10% by CAP was 0.938 (95% confidence interval, 0.896 to 0.967), and a CAP of >259 dB/m yielded a sensitivity of 84.2% and a specificity of 92.4%.

CONCLUSION

The CAP measured using TE was significantly correlated with MaS and accurately detected substantial MaS in potential living liver donors. The CAP is a promising tool for the noninvasive diagnosis of MaS and may be used to screen unsuitable living liver donor candidates.

Magnetic Resonance Spectroscopy of Hepatic Fat from Fundamental to Clinical Applications

The number of individuals suffering from fatty liver is increasing worldwide, leading to interest in the noninvasive study of liver fat. Magnetic resonance spectroscopy (MRS) is a powerful tool that allows direct quantification of metabolites in tissue or areas of interest. MRS has been applied in both research and clinical studies to assess liver fat noninvasively in vivo. MRS has also demonstrated excellent performance in liver fat assessment with high sensitivity and specificity compared to biopsy and other imaging modalities. Because of these qualities, MRS has been generally accepted as the reference standard for the noninvasive measurement of liver steatosis. MRS is an evolving technique with high potential as a diagnostic tool in the clinical setting. This review aims to provide a brief overview of the MRS principle for liver fat assessment and its application, and to summarize the current state of MRS study in comparison to other techniques.

Non-alcoholic fatty liver disease in adults: clinic, diagnostics, treatment. Guidelines for therapists, third version

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A prospective 5-year study on the use of transient elastography to monitor the improvement of non-alcoholic fatty liver disease following bariatric surgery

Liver stiffness measurement (LSM) by transient elastography (TE) is a non-invasive assessment for diagnosing and staging liver fibrosis in non-alcoholic fatty liver disease (NAFLD). Evidence on its role as a longitudinal monitoring tool is lacking. This study aims to evaluate the role of TE in monitoring NAFLD improvement following bariatric surgery. This study prospectively recruited 101 morbidly obese patients undergoing laparoscopic bariatric surgery for intraoperative liver biopsy. Thirty-seven patients of the cohort received perioperative TE. Postoperative anthropometric, biochemical and LSM data were collected annually for 5 years. In 101 patients receiving liver biopsy (mean age 40.0 ± 10.3 years, mean body-mass-index (BMI) 40.0 ± 5.7 kg/m²), NASH and liver fibrosis were diagnosed in 42 (41.6%) and 48 (47.5%) patients respectively. There were 29 (28.7%) stage 1, 11 (10.9%) stage 2, 7 (6.9%) stage 3, and 1 (1.0%) stage 4 fibrosis. In 37 patients receiving TE (mean age 38.9 ± 10.8 years, mean BMI 41.1 ± 5.6 kg/m²), the percentages of total weight loss were 21.1 ± 7.6% at 1 year, 19.7 ± 8.3% at 3 years, and 17.1 ± 7.0% at 5 years after surgery. The mean LSM reduced significantly from 9.8 ± 4.6 kPa at baseline to 6.9 ± 3.4 kPa at 1 year, 7.3 ± 3.0 kPa at 3 years, and 6.8 ± 2.6 kPa at 5 years (P = 0.002). Using pre-defined LSM cut-offs, the rates of significant fibrosis, advanced fibrosis and cirrhosis being ruled out at 5 years improved from baseline values of 43.7 to 87.5% (P < 0.001), 56.8 to 91.7% (P < 0.001), and 64.9 to 91.7% (P < 0.001), respectively. TE was a useful monitoring tool in demonstrating the improvement of liver fibrosis following bariatric surgery.

Clinical Feasibility of Quantitative Ultrasound Imaging for Suspected Hepatic Steatosis: Intra- and Inter-examiner Reliability and Correlation with Controlled Attenuation Parameter

This study was aimed at investigating the clinical feasibility of quantitative ultrasound (QUS) imaging in the evaluation of suspected hepatic steatosis through assessment of the reliability of measurements and its correlation with the controlled attenuation parameter (CAP). This retrospective study included 117 patients who underwent liver B-mode ultrasound (US) with QUS imaging with a clinical US machine (RS85, Samsung Medison, Seoul, Korea) and CAP measurements between December 2019 and March 2020. For QUS examination, tissue attenuation imaging (TAI) and tissue scatter-distribution imaging (TSI) parameters were obtained. Intra- and inter-examiner reliability were assessed using intra-class correlation coefficients (ICCs), and QUS imaging parameters were correlated with CAP measurements using Spearman's correlation analysis. TAI and TSI revealed excellent intra- and inter-examiner reliability with ICCs of 0.994 and 0.975 and 0.991 and 0.947, respectively. Both TAI and TSI were significantly positively correlated with CAP values. QUS imaging provided good intra-and inter-observer reliability and correlated well with CAP in assessing suspected hepatic steatosis.

Diagnostic Performance of Noninvasive Methods for Liver Biopsy by Fibroscan in Pediatric

Liver biopsy is the gold standard for the diagnosis and management of various liver diseases; however, noninvasive diagnostic modalities may help prevent adverse effects of anesthesia, prolonged hospitalization, sampling error, and other serious complications, particularly in pediatric patients. The aim of this study is to compare the results of liver biopsy and fibroscan in children with chronic liver diseases. All patients presenting chronic liver disease admitted in the ward or clinic of Tehran's Children Medical Center were enrolled in the study. Required laboratory tests were performed to diagnose the disease, followed by elastography using fibroscan 402 (M-probe) Echosens machine and liver biopsy using Menghini technique. Samples were scored by using METAVIR scoring system. Thirty-two patients were reported (68.8%, female) with autoimmune hepatitis (18.8%), Wilson disease (12.5%), and glycogen storage disease (12.5%). The most common pathologic stage and fibroscan result was stage III and F0 (46.9%), respectively. Association between pathology and fibroscan results was not significant. Nonetheless, age and diagnosis, age and Fibroscan score, and pathology and liver function test were significantly associated with each other. Fibroscan cannot be used as an alternative to liver biopsy; however, it can be a useful accessory tool.

Noninvasive evaluation of liver fibrosis: comparison of the stretched exponential diffusion-weighted model to other diffusion-weighted MRI models and transient elastography

OBJECTIVES

To compare the diagnostic performance of the stretched exponential model to those of other DWI models and transient elastography (TE) and to evaluate the influence of confounding factors on the staging of liver fibrosis.

METHODS

This retrospective study included 78 consecutive patients who underwent both DWI and TE. The distributed diffusion coefficient (DDC) and intravoxel heterogeneity index (α) from the stretched exponential model, apparent diffusion coefficient (ADC), perfusion fraction (f), pseudodiffusion coefficient (D_p), true diffusion coefficient (D_t), and TE were obtained. Associations between imaging parameters and pathological fibrosis, inflammation, and steatosis were evaluated using Spearman's correlation and multiple regression analysis. Diagnostic accuracy of parameters for fibrosis staging was assessed via the Obuchowski measures.

RESULTS

DDC was the only parameter to differ between F0-1 and F2-3 (p < 0.001) and between F2-3 and F4 (p = 0.013). DDC showed significant correlation with fibrosis (p < 0.001) and inflammation (p = 0.001), but not with steatosis (p = 0.619), and was independently associated with only fibrosis in multiple regression analysis (β = - 0.114, p < 0.001). ADC, D_p, and D_t showed a significant correlation with steatosis (ps ≤ 0.038). DDC showed the highest diagnostic performance for liver fibrosis (0.717; 95% confidence interval, 0.653-0.765) followed by TE (0.681, 0.623-0.733) without a significant difference between DDC and TE (p > 0.999).

CONCLUSIONS

DDC from the stretched exponential model is the most accurate DWI parameter with no confounding effect from steatosis and with overall similar diagnostic performance to TE.

KEY POINTS

• The distributed diffusion coefficient (DDC) from the stretched exponential model is the most accurate DWI parameter for staging liver fibrosis. • DDC and transient elastography have similar good diagnostic performance for evaluating liver fibrosis. • The stretched exponential DWI model has no confounding effect by steatosis, unlike other DWI models.