Elsevier

Journal of Hepatology

Volume 54, Issue 4, April 2011, Pages 650-659
Journal of Hepatology

Research Article
Elastography for the diagnosis of severity of fibrosis in chronic liver disease: A meta-analysis of diagnostic accuracy

https://doi.org/10.1016/j.jhep.2010.07.033Get rights and content

Background & Aims

Transient elastography is a non-invasive method, for the assessment of hepatic fibrosis, developed as an alternative to liver biopsy. We studied the performance of elastography for diagnosis of fibrosis using meta-analysis.

Methods

MEDLINE, EMBASE, SCI, Cochrane Library, conference abstracts books, and article references were searched. We included studies using biopsy as a reference standard, with the data necessary to calculate the true and false positive, true and false negative diagnostic results of elastography for a fibrosis stage, and with a 3-month maximum interval between tests. The quality of the studies was rated with the QUADAS tool.

Results

We identified 40 eligible studies. Summary sensitivity and specificity was 0.79 (95% CI 0.74–0.82) and 0.78 (95% CI 0.72–0.83) for F2 stage and 0.83 (95% CI 0.79–0.86) and 0.89 (95% CI 0.87–0.91) for cirrhosis. After an elastography result at/over the threshold value for F2 or cirrhosis (“positive” result), the corresponding post-test probability for their presence (if pre-test probability was 50%) was 78%, and 88% respectively, while, if values were below these thresholds (“negative” result), the post-test probability was 21% and 16%, respectively. No optimal stiffness cut-offs for individual fibrosis stages were validated in independent cohorts and cut-offs had a wide range and overlap within and between stages.

Conclusions

Elastography theoretically has good sensitivity and specificity for cirrhosis (and less for lesser degrees of fibrosis); however, it should be cautiously applied to everyday clinical practice because there is no validation of the stiffness cut-offs for the various stages. Such validation is required before elastography is considered sufficiently accurate for non-invasive staging of fibrosis.

Introduction

Liver fibrosis represents the final common outcome of chronic liver injury and is often progressive, eventually evolving into cirrhosis [1]. Cirrhosis is the severest form of fibrosis with the worst clinical outcomes.

Currently, histological examination of a liver biopsy specimen is the reference standard for the diagnosis, staging, and monitoring of liver fibrosis [2]. However, it is invasive and can lead to fatal bleeding [2].

Transient elastography is a non-invasive method of quantifying fibrosis developed as an alternative to liver biopsy. Ultrasound elastography analyses ultrasound frequency waves which are related to the elasticity (deforming capacity) of the liver. It is simple, highly reproducible, and can be completed in 10 min in an outpatient setting with no significant expertise [3]. Magnetic resonance elastography involves measuring the elasticity of liver tissues using complex algorithms [4]. An increasing number of studies have evaluated the accuracy of elastography in the staging of fibrosis and compared it to liver biopsy.

In the present study, we used meta-analysis to assess the performance of elastography in the diagnosis of severity of liver fibrosis using liver biopsy as the reference standard.

Section snippets

Criteria for the selection of studies

We included full papers and abstracts, without language restrictions that (1) evaluated elastography in the diagnosis of severity of liver fibrosis or monitoring thereof, using liver biopsy as the reference standard, and (2) reported on data necessary to calculate the true positive false positive, true negative and false negative diagnostic results of elastography for the diagnosis of a fibrosis stage based on a defined cut-off point for liver stiffness. If such data were unavailable, the

Description of studies

We identified 1289 references. The reference flow is shown in Fig. 1. The inclusion criteria were fulfilled in 43 studies (35 full papers, eight abstracts) [3], [4], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54]. From these, three studies were excluded, as they evaluated magnetic resonance

Discussion

In our meta-analysis, we evaluated the diagnostic accuracy of transient elastography in the staging of liver fibrosis, as reported in 40 studies. Although three meta-analyses have already been published on this subject [57], [58], [59], our meta-analysis evaluates 29 different studies compared to these, with an overlap of 25% or less. Moreover, none of these meta-analyses has used the optimal statistical methods of combining the studies, i.e. HSROC or bivariate model [8]. Furthermore, none has

Conflict of interest

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

Acknowledgements

E.A. Tsochatzis has received an educational grant from the Hellenic Association for the Study of the Liver.

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