Performance of Transient Elastography for the Staging of Liver Fibrosis in Patients with Chronic Hepatitis B: A Meta-Analysis

<div><h3>Background</h3><p>Transient elastography (TE), a <b><u>non-invasive tool</u></b> that measures liver stiffness, has been evaluated in meta-analyses for effectiveness in assessing liver fibrosis in European populations with chronic hepatitis C (CHC). However, these data cannot be extrapolated to populations in Asian countries, where chronic hepatitis B (CHB) is more prevalent. In this study, we performed a meta-analysis to assess the overall performance of TE for assessing liver fibrosis in patients with CHB<b>.</b></p> <h3>Methods</h3><p>Studies from the literature and international conference abstracts which enrolled only patients with CHB or performed a subgroup analysis of such patients were enrolled. Combined effects were calculated using area under the receiver operating characteristic curves (AUROC) and diagnostic accuracy values of each study.</p> <h3>Result</h3><p>A total of 18 studies comprising 2,772 patients were analyzed. The mean AUROCs for the diagnosis of significant fibrosis (F2), severe fibrosis (F3), and cirrhosis (F4) were 0.859 (95% confidence interval [CI], 0.857–0.860), 0.887 (95% CI, 0.886–0.887), and 0.929 (95% CI, 0.928–0.929), respectively. The estimated cutoff for F2 was 7.9 (range, 6.1–11.8) kPa, with a sensitivity of 74.3% and specificity of 78.3%. For F3, the cutoff value was determined to be 8.8 (range, 8.1–9.7) kPa, with a sensitivity of 74.0% and specificity of 63.8%. The cutoff value for F4 was 11.7 (range, 7.3–17.5) kPa, with a sensitivity of 84.6% and specificity of 81.5%.</p> <h3>Conclusion</h3><p>TE can be performed with good diagnostic accuracy for quantifying liver fibrosis in patients with CHB.</p> </div

Baseline and follow-up LS and cardiologic parameters.

<p>Variables are expressed as medians (range) or n (%).</p><p>LS, liver stiffness; POD, post-operative day; LVEF, left ventricular ejection fraction; LAV, left atrial volume; LAVI, left atrial volume index; LVESD, left ventricle end systolic diameter; LVEDD, left ventricle end diastolic diameter; RVP, right ventricular pressure.</p

Liver stiffness at baseline, POD7, and POD90.

<p>(A) Patients with valve operation; LS increased minimally on POD7, but decreased significantly on POD90. (B) Patients with varicose vein operation; LS remained normal without significant interval changes during the study period. LS, liver stiffness; POD, post-operative day.</p

Correlation between liver stiffness and cardiologic parameters in patients with valve operation.

<p>LS was significantly correlated with NT-proBNP (ρ  =  0.412, <i>P</i>  =  0.021), LVEF (ρ  =  −0.494, <i>P</i>  =  0.005), and CVPop (ρ  =  0.555, <i>P</i>  =  0.001). LS was significantly correlated with NT-proBNP (ρ  =  0.526, <i>P</i>  =  0.002) and RVP (ρ  =  0.572, <i>P</i> =  0.001) on POD7. LS was significantly correlated with NT-proBNP (ρ  =  0.590, <i>P</i>  =  0.001) on POD90. LS, liver stiffness; NT-pro BNP, N-terminal pro brain natriuretic peptide; LVEF, left ventricular ejection fraction; CVPop, central venous pressure during the operation; POD, postoperative day; RVP, right ventricular pressure.</p

Discrimination of Nonalcoholic Steatohepatitis Using Transient Elastography in Patients with Nonalcoholic Fatty Liver Disease

<div><p>Background/aims</p><p>The accuracy of noninvasive markers to discriminate nonalcoholic steatohepatitis (NASH) is unsatisfactory. We investigated whether transient elastography (TE) could discriminate patients with NASH from those with nonalcoholic fatty liver disease (NAFLD).</p><p>Methods</p><p>The patients suspected of NAFLD who underwent liver biopsy and concomitant TE were recruited from five tertiary centers between November 2011 and December 2013.</p><p>Results</p><p>The study population (n = 183) exhibited a mean age of 40.6 years and male predominance (n = 111, 60.7%). Of the study participants, 89 (48.6%) had non-NASH and 94 (51.4%) had NASH. The controlled attenuation parameter (CAP) and liver stiffness (LS) were significantly correlated with the degrees of steatosis (r = 0.656, <i>P</i><0.001) and fibrosis (r = 0.714, <i>P</i><0.001), respectively. The optimal cut-off values for steatosis were 247 dB/m for S1, 280 dB/m for S2, and 300 dB/m for S3. Based on the independent predictors derived from multivariate analysis [<i>P</i> = 0.044, odds ratio (OR) 4.133, 95% confidence interval (CI) 1.037–16.470 for <u><i>C</i></u>AP>250 dB/m; <i>P</i> = 0.013, OR 3.399, 95% CI 1.295–8.291 for <u><i>L</i></u>S>7.0 kPa; and <i>P</i><0.001, OR 7.557, 95% CI 2.997–19.059 for <u><i>A</i></u>lanine aminotransferase>60 IU/L], we developed a novel CLA model for discriminating patients with NASH. The CLA model showed good discriminatory capability, with an area under the receiver operating characteristic curve (AUROC) of 0.812 (95% CI 0.724–0.880). To assess discriminatory power, the AUROCs, as determined by the bootstrap method, remained largely unchanged between iterations, with an average value of 0.833 (95% CI 0.740–0.893).</p><p>Conclusion</p><p>This novel TE-based CLA model showed acceptable accuracy in discriminating NASH from simple steatosis. However, further studies are required for external validation.</p></div

The distribution of LS and CAP values according to histologic fibrosis and steatosis grade.

<p>The bar lines mean the range of each grade of steatosis and fibrosis. LS, liver stiffness; CAP, controlled attenuation parameter.</p

Diagnostic performance of LS for assessing liver fibrosis in patients with NAFLD

<p>Diagnostic performance of LS for assessing liver fibrosis in patients with NAFLD</p

CLA score and corresponding NASH prevalence.

<p>CLA score and corresponding NASH prevalence.</p

The relationship between visceral obesity and hepatic steatosis measured by controlled attenuation parameter

<div><p>Background</p><p>Nonalcoholic fatty liver disease (NAFLD) is closely related with obesity. However, obese subjects, generally represented by high BMI, do not always develop NAFLD. A number of possible causes of NAFLD have been studied, but the exact mechanism has not yet been elucidated.</p><p>Methods</p><p>A total of 304 consecutive subjects who underwent general health examinations including abdominal ultrasonography, transient elastography and abdominal fat computed tomography were prospectively enrolled. Significant steatosis was diagnosed by ultrasonography and controlled attenuation parameter (CAP) assessed by transient elastography.</p><p>Results</p><p>Visceral fat area (VFA) was significantly related to hepatic steatosis assessed by CAP, whereas body mass index (BMI) was related to CAP only in univariate analysis. In multiple logistic regression analysis, VFA (odds ratio [OR], 1.010; 95% confidence interval [CI], 1.001–1.019; <i>P</i> = 0.028) and triglycerides (TG) (OR, 1.006; 95% CI, 1.001–1.011; <i>P</i> = 0.022) were independent risk factors for significant hepatic steatosis. The risk of significant hepatic steatosis was higher in patients with higher VFA: the OR was 4.838 (<i>P</i><0.001; 95% CI, 2.912–8.039) for 1002 and 7.474 (<i>P</i><0.001; 95% CI, 2.462–22.693) for VFA >200 cm², compared to patients with a VFA ≤100 cm².</p><p>Conclusions</p><p>Our data demonstrated that VFA and TG is significantly related to hepatic steatosis assessed by CAP not BMI. This finding suggests that surveillance for subjects with NAFLD should incorporate an indicator of visceral obesity, and not simply rely on BMI.</p></div

Factors Affecting the Accuracy of Controlled Attenuation Parameter (CAP) in Assessing Hepatic Steatosis in Patients with Chronic Liver Disease

<div><p>Background & Aims</p><p>Controlled attenuation parameter (CAP) can measure hepatic steatosis. However, factors affecting its accuracy have not been described yet. This study investigated predictors of discordance between liver biopsy (LB) and CAP.</p><p>Methods</p><p>A total of 161 consecutive patients with chronic liver disease who underwent LB and CAP were enrolled prospectively. Histological steatosis was graded as S0 (<5%), S1 (5–33%), S2 (34–66%), and S3 (>66% of hepatocytes). Cutoff CAP values were calculated from our cohort (250, 301, and 325 dB/m for ≥S1, ≥S2, and S3). Discordance was defined as a discrepancy of at least two steatosis stages between LB and CAP.</p><p>Results</p><p>The median age (102 males and 59 females) was 49 years. Repartition of histological steatosis was as follows; S0 26.1% (n = 42), S1 49.7% (n = 80), S2 20.5% (n = 33), and S3 3.7% (n = 6). In multivariate linear regression analysis, CAP value was independently associated with steatosis grade along with body mass index (BMI) and interquartile range/median of CAP value (IQR/M_CAP) (all P<0.05). Discordance was identified in 13 (8.1%) patients. In multivariate analysis, histological S3 (odd ratio [OR], 9.573; 95% confidence interval [CI], 1.207–75.931; <i>P</i> = 0.033) and CAP value (OR, 1.020; 95% CI, 1.006–1.034; <i>P</i> = 0.006) were significantly associated with discordance, when adjusting for BMI, IQR/M_CAP, and necroinflammation, reflected by histological activity or ALT level.</p><p>Conclusions</p><p>Patients with high grade steatosis or high CAP values have a higher risk of discordance between LB and CAP. Further studies are needed to improve the accuracy of CAP interpretation, especially in patients with higher CAP values.</p></div