Elsevier

Journal of Hepatology

Volume 54, Issue 1, January 2011, Pages 64-71
Journal of Hepatology

Research Article
Reliability of transient elastography for the detection of fibrosis in Non-Alcoholic Fatty Liver Disease and chronic viral hepatitis

https://doi.org/10.1016/j.jhep.2010.06.022Get rights and content

Background & Aims

Transient elastography (TE) is validated in chronic hepatitis C (CHC) to evaluate hepatic fibrosis; however, limited data are available in chronic hepatitis B (CHB) and Non-Alcoholic Fatty Liver Disease (NAFLD). This prospective study is aimed to assess the accuracy and the efficacy of TE for the detection of fibrosis in patients with chronic liver disease of different etiology and to evaluate the effect of steatosis on the liver stiffness measurement (LSM).

Methods

TE was performed in 219 consecutive patients with chronic liver disease (35% CHC, 32% CHB, and 33% NAFLD) within 6 months of the liver biopsy.

Results

LSM was related to the fibrosis stage in each group (CHC: p = 0.596, p <0.001; CHB: p = 0.418, p <0.001; NAFLD: p = 0.573, p <0.001), but the correlation was less strong in CHB and NAFLD than in CHC patients. In CHB patients with histological cirrhosis (F4), the median stiffness value was almost two times lower than in patients with severe fibrosis (F3). In NAFLD patients with advanced fibrosis (F3) and severe steatosis (>33%), the LSM values were lower than expected and were similar to those of patients with initial fibrosis (F1) and fat <33%. TE underestimated the stage of fibrosis in 75% of patients with F3 and steatosis >33%. At multiple logistic regression analysis, in CHC and CHB patients, LSM was the only predictive variable of severe fibrosis/cirrhosis (OR = 1.42, p = 0.003 and OR = 1.354, p = 0.003, respectively), while in NAFLD subjects BMI and AST (OR = 1.433, p = 0.002 and OR = 1.053, p = 0.020, respectively) but not LSM were independently related with advanced fibrosis and cirrhosis.

Conclusions

This study confirms that TE can be considered a valid support to detect fibrosis in chronic liver disease related to HCV but it should be interpreted cautiously in CHB and NAFLD patients, where host or disease-related factors may modify its accuracy.

Introduction

The prognosis of hepatic liver diseases as well as the success of specific treatments depends on the extent of liver fibrosis. Liver biopsy (LB) is still considered the “gold standard” to evaluate liver damage. Although generally safe, this procedure is invasive and the risk/benefit ratio is seldom uncertain, or patients may not accept the discomfort related to the procedure [1], [2]. The accuracy of LB in assessing fibrosis varies depending on inter-observer variability and on sampling error, resulting in up to 30% false negative results and underestimation of cirrhosis, especially for small or fragmented specimens [3], [4], [5], [6], [7].

In the last few years, non-invasive tests that reflect the full spectrum of liver fibrosis have been developed [8], [9], [10], [11]. Transient elastography (TE, Fibroscan, Echosens, Paris, France) is a non-invasive device which measures liver stiffness, as a function of the extent of hepatic fibrosis [12], [13]. Liver stiffness measurement (LSM) appears to be a reliable tool to identify hepatic fibrosis and cirrhosis mainly in patients with chronic hepatitis C (CHC) [12], [14], [15], [16], [17] but limited data are available in patients with chronic hepatitis B (CHB) [18], [19] or Non-Alcoholic Fatty Liver Disease (NAFLD) [20], [21], [22]. The cirrhosis of patients with CHB is often macro nodular and may display a reduced amount of fibrosis compared to micro nodular cirrhosis, thus leading to an underestimation of LSM. In NAFLD patients, various degrees of hepatic steatosis may attenuate the elastic shear wave, possibly leading again to an underestimation of liver damage.

The aims of this prospective study were to assess the accuracy and the efficacy of TE for the detection of fibrosis in patients with liver disease of different etiology (CHC, CHB, and NAFLD) and to evaluate the effect of steatosis on liver stiffness measurements.

Section snippets

Study subjects

Between January 2007 and March 2009, all patients with viral or metabolic chronic liver disease, who underwent liver biopsy at the Hepatology Unit in San Giovanni Battista Hospital, were prospectively enrolled. Diagnosis of chronic liver disease was made by standard criteria. Chronic hepatitis B (CHB) was defined by the presence of Hepatitis B surface antigen and core antibody with detectable HBV DNA at PCR analysis. Chronic hepatitis C (CHC) was defined by detectable anti-hepatitis C virus

Clinical, biochemical, and histological data

A total of 290 patients were initially enrolled in the study. Twenty-one patients (8%) were excluded because of unsuccessful liver stiffness measurements (less than 10 valid measurements and/or a success rate lower the 60%), due to obesity and thickness of the thoracic wall (>2 cm). Ten more cases were excluded because LB specimens were shorter than 20 mm (n = 7) or diagnosis was uncertain (n = 3). Analysis was carried out in 259 subjects. Seventy-seven had a diagnosis of CHC, 70 of CHB, 72 of NAFLD,

Discussion

We herein report a single center experience for the surrogate assessment of fibrosis by Fibroscan in a cohort of patients according to the etiology of chronic liver disease. In order to analyze the accuracy of TE in hepatitis B and NAFLD in comparison with the standard hepatitis C, we sought to exclude factors known to affect TE measurement. Patients with acute liver disease, acute reactivation on chronic liver damage, or alcohol abuse were excluded to avoid influence of acute

Conflict of interest

The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

References (41)

  • C. Rigamonti et al.

    Do not trivialize the Fibroscan examination, value its accuracy

    J Hepatol

    (2007)
  • D. Roulot et al.

    Liver stiffness values in apparently healthy subjects: influence of gender and metabolic syndrome

    J Hepatol

    (2008)
  • N.F. Schwenzer et al.

    Non-invasive assessment and quantification of liver steatosis by ultrasound, computed tomography and magnetic resonance

    J Hepatol

    (2009)
  • A.A. Bravoo et al.

    Liver biopsy

    N Eng J Med

    (2001)
  • L. Castéra et al.

    Pain experienced during percutaneous liver biopsy

    Hepatology

    (1999)
  • I. Siddique et al.

    Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection

    Scand J Gastroenterol

    (2003)
  • The French METAVIR Cooperative Study Group

    Intraobserver and interobserver variations in liver biopsy interpretation in patients with chronic hepatitis C

    Hepatol

    (1994)
  • G. Sebastiani

    Non-invasive assessment of liver fibrosis in chronic liver diseases: implementation in clinical practice and decisional algorithm

    World J Gastroenterol

    (2009)
  • M. Friedricht-Rust et al.

    Assessment of liver fibrosis and steatosis in PBC with FibroScan, MRI, MR-spectroscopy, and Serum Markers

    J Clin Gastroenterol

    (2010)
  • T. Poynard et al.

    Assessment of liver fibrosis: noninvasive means

    Saudi J Gastroenterol

    (2008)
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