Papatheodoridi, M

Pinzani, M

Tsochatzis, E

English

UCL Discovery

We would like to thank Dr Ji and co-authors and Dr Cristoferi and co-authors for their interest in our study [1], that also provides us the opportunity to clarify several important points. Dr Ji has tested the revised elastography thresholds we propose for the assessment of compensated advanced chronic liver disease in a cohort of 220 patients with MAFLD. More than half of these patients had co-existing HBV infection with an unknown treatment status, while 42% had traditional NAFLD. The authors demonstrated an excellent sensitivity of the low cut-off but a somewhat suboptimal specificity of the 12 KPa cut-off (81.5%). The term MAFLD is an umbrella term that potentially includes any cause of liver disease provided there is a co-existence of metabolic abnormalities. It would be very helpful if the authors have reported separately the diagnostic performance of the criteria in traditional NAFLD versus patients with HBV and metabolic abnormalities. It would also be crucial to report the treatment status of the patients with HBV. Our cohort included patients with HBV who were not receiving antiviral treatment. It is established that long term antiviral treatment reduces liver stiffness values in patients with HBV [2]. Our hypothesis is that the suboptimal performance of the 12 KPa threshold is driven by the proportion of patients with treated HBV rather than the elusive diagnosis of MAFLD. To corroborate this, a recent cohort study from Hong Kong confirmed the diagnostic accuracy of our proposed revised criteria in patients with Chinese ethnicity and NAFLD [3].  Dr Cristoferi questions the need for dual cut-offs, and the use of the patients in the “grey zone” area for developing the model to classify such patients. We have previously shown that the use of currently available non-invasive tests at single cut-offs do not have sufficient diagnostic accuracy for the detection of cirrhosis, and this is also true for cACLD, as their diagnostic accuracy is even lower [4]. Moreover, there is not an established single Fibroscan cut-off, as most studies reported on post-hoc cut-offs that better suited their dataset [5]. The optional single cut-off for cACLD in our population was 9 KPa, but it would have a sensitivity and specificity of 80% which would be suboptimal for individualized decisions. We strongly believe that using the “grey zone” patients to develop the model for their classification is the statistically correct way, as the model is applicable to this population rather than the whole study cohort.  In conclusion, we stand by and strongly support the use of dual cut-offs for cACLD in patients with NAFLD, ALD and untreated HBV and HCV at the thresholds reported in our paper.   [1] Papatheodoridi M, Hiriart JB, Lupsor-Platon M, Bronte F, Boursier J, Elshaarawy O, et al. Refining the Baveno VI elastography criteria for the definition of compensated advanced chronic liver disease. Journal of hepatology 2021;74:1109-1116. [2] Crossan C, Tsochatzis EA, Longworth L, Gurusamy K, Papastergiou V, Thalassinos E, et al. Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis B in the UK: systematic review and economic evaluation. Journal of viral hepatitis 2016;23:139-149. [3] Zhou YJ, Gao F, Liu WY, Wong GL, Mahadeva S, Raihan Nik Mustapha N, et al. Screening for compensated advanced chronic liver disease using refined Baveno VI elastography cutoffs in Asian patients with nonalcoholic fatty liver disease. Alimentary pharmacology & therapeutics 2021. [4] Majumdar A, Campos S, Gurusamy K, Pinzani M, Tsochatzis EA. Defining the Minimum Acceptable Diagnostic Accuracy of Noninvasive Fibrosis Testing in Cirrhosis: A Decision Analytic Modeling Study. Hepatology 2020;71:627-642. [5] Crossan C, Tsochatzis EA, Longworth L, Gurusamy K, Davidson B, Rodriguez-Peralvarez M, et al. Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation. Health technology assessment (Winchester, England) 2015;19:1-409, v-vi.  

Reply to: “Baveno VI elastography criteria for ruling in cACLD works well in patients with MAFLD” and “Transient elastography in chronic liver disease: Beware of the cut-offs!”

https://discovery.ucl.ac.uk/id/eprint/10138482/3/Tsochatzis_Reply%20to-%20%22Baveno%20VI%20elastography%20criteria%20for%20ruling%20in%20cACLD%20works%20well%20in%20patients%20with%20MAFLD%22%20and%20%22Transient%20elastography%20in%20chronic%20liver%20disease-%20Beware%20of%20the%20cut-offs%21%22_AAM.pdf

Reply to: “Baveno VI elastography criteria for ruling in cACLD works well in patients with MAFLD” and “Transient elastography in chronic liver disease: Beware of the cut-offs!”

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