Factors influencing reliability of liver stiffness measurements using transient elastography (M-probe)-monocentric experience

Screening for advanced liver fibrosis due to metabolic dysfunction-associated steatotic liver disease alongside retina scanning in people with type 2 diabetes: a cross-sectional study

BACKGROUND

International guidelines suggest screening for advanced fibrosis due to metabolic dysfunction-associated steatotic liver disease in people with type 2 diabetes, but how to implement these guidelines in clinical care remains unclear. We hypothesise that examination with VCTE could be implemented simultaneously with retina scanning with a high acceptance rate in people with type 2 diabetes.

METHODS

In this cross-sectional study, we offered VCTE to people with type 2 diabetes referred to routine retina scanning in a large retina scanning facility in Stockholm, Sweden. We excluded people with type 1 diabetes, currently pregnant, with known liver disease, reporting high alcohol consumption, who did not speak Swedish, or younger than 18 years. Between Nov 6, 2020, and June 20, 2023, we conducted surveys with included participants and collected data from medical records on diabetes retinopathy, sex, and VCTE measurements. Increased liver stiffness was defined as at least 8·0 kPa, and possible advanced fibrosis as more than 12·0 kPa. Presence of metabolic dysfunction-associated steatotic liver disease was defined as a controlled attenuation parameter (CAP) value of 280 dB/m or higher. Participants with a liver stiffness measurement of at least 8·0 kPa or those with unreliable measurements were subsequently referred for a secondary evaluation at a liver specialist, including a follow-up liver stiffness measurement with VCTE. The primary outcome was the proportion of eligible people approached for screening who accepted. Secondary outcomes were the prevalence of elevated liver stiffness (≥8·0 kPa or >12·0 kPa), presence of metabolic dysfunction-associated steatotic liver disease, and the proportion of elevated liver stiffness readings at the first VCTE examination that were not elevated in the secondary evaluation with a liver specialist. Secondary outcomes were assessed in all participants who accepted screening, except false positives, which were assessed only in participants who had a second examination.

FINDINGS

1301 participants were eligible to undergo assessment with VCTE, which was accepted by 1005 (77·2%). 973 (96·8%) participants had complete measurements, of whom 504 (51·8%) had CAP values of 280 dB/m or higher, indicating metabolic dysfunction-associated steatotic liver disease. Of 977 participants with reliable liver stiffness measurements, 154 (15·8%) had values of at least 8·0 kPa, suggestive of liver fibrosis, and 49 (5·0%) had values higher than 12·0 kPa, indicating possible advanced fibrosis. However, upon reassessment with a second VCTE after referral, 56 (45·2%) of 124 individuals had values less than 8·0 kPa. 74 (7·4%) of 1005 participants had a final liver stiffness of at least 8·0 kPa; 29 (2·9%) had values greater than 12·0 kPa.

INTERPRETATION

Simultaneous examination with VCTE alongside retina scanning had a high acceptance rate among people with type 2 diabetes and could be a strategy for case-finding of people with fibrosis due to metabolic dysfunction-associated steatotic liver disease. However, a high proportion of participants in our study with elevated liver stiffness measurement at the screening visit did not have an elevated liver stiffness measurement at secondary evaluation, suggesting false-positive findings were common.

FUNDING

Gilead Sciences, Pfizer, Region Stockholm, Åke Wiberg Foundation, and Bengt Ihre Foundation.

Prevalence of Steatotic Liver Disease Subtypes and Association With Metabolic Risk Factors in the Framingham Heart Study

Recent updates in nomenclature and diagnostic criteria encompass the diverse phenotypes associated with steatotic liver disease (SLD).1 These updates aim to reflect the current understanding of SLD, promote disease awareness and research, and reduce stigma. Notably, the term metabolic dysfunction-associated steatotic liver disease (MASLD) is defined as hepatic steatosis with at least 1 of 5 cardiometabolic criteria without any other cause of steatosis. A new category, MetALD, includes those with MASLD and high alcohol intake.1 We aimed to characterize SLD using this nomenclature in the Framingham Heart Study (FHS) and to quantify its association with cardiometabolic risk factors.

The Role of ElastPQ in Assessing Liver Stiffness for Non-Alcoholic Fatty Liver Disease in Patients Treated with Atypical Antipsychotic Drugs

Objective

To evaluate the role of elastography point quantification (ElastPQ) for the quantitative assessment of stiffness in the fatty liver disease in mental disorder patients and to provide a noninvasive detection method for non-alcoholic fatty liver (NAFLD) caused by atypical antipsychotics drugs (AAPDs).

Methods

A total number of 168 mental disorder patients treated with AAPDs and 58 healthy volunteers were enrolled in this study. All the subjects underwent ultrasound and ElastPQ tests. The basic data of the patients were analyzed.

Results

BMI, liver function, and the value of ElastPQ were considerably higher in the patient group than that in the healthy volunteers. The values of liver stiffness obtained by ElastPQ were increased gradually from 3.48(3.14-3.81) kPa in the normal liver to 8.15(6.44-9.88) in the severe fatty liver. The receiver operating characteristic (ROC) for the diagnosis of fatty liver with ElastPQ were 0.85, 0.79, 0.80, and 0.87 for the diagnosis of normal, mild, moderate, and severe steatosis, respectively, with a sensitive/specificity of 79%/76.4%, 85.7%/78.3%, 86.2%/73%, and 81.3%/82.1%, correspondingly. Moreover, ElastPQ in the olanzapine group was higher than those in the risperidone and aripiprazole groups (5.11(3.83-5.61) kPa vs 4.35(3.63-4.98) kPa, P < 0.05; 5.11(3.83-5.61) kPa vs 4.79(4.18-5.24) kPa, P < 0.05). After one-year treatment, the value of ElastPQ was 4.43(3.85-5.22) kPa, but it was 5.81(5.09-7.33) kPa in patients treated for more than three years. This value increased with treatment prolongation (P < 0.05).

Conclusion

ElastPQ is a real-time, quantitative method for assessing the stiffness of NAFLD. The liver stiffness value could be varied in the different stages of fatty liver. Olanzapine has a considerable influence on liver stiffness. The long-term use of AAPDs can increase the stiffness value of fatty liver.

Dynamic Changes in Liver Stiffness in Patients with Chronic Hepatitis B Undergoing Antiviral Therapy

This is a retrospective single-center study that included 87 subjects. All subjects had chronic hepatitis B or HBV cirrhosis and underwent nucleos(t)ide analogs (NUC) treatment for more than one year. The study aimed to evaluate the dynamic changes in liver stiffness (LS) measured by transient elastography (TE) during a median interval of 64 months. Patients were assessed prior to starting therapy and followed up annually. Liver stiffness measurements (LSM) were performed annually, and ten valid LSMs were obtained in each session. Reliable LSMs were defined as the median value of 10 measurements with Interquartile range/median (IQR/M) ≤ 30%. A significant decrease in liver stiffness values (p < 0.001) was observed during follow-up. In patients with liver cirrhosis, the LSMs decreased significantly after only one year, 24.6 ± 4.3 kPa vs. 13.5 ± 4.2 kPa (p = 0.007), whereas the decrease in non-cirrhotic patients was not significant, 7.31 ± 3.62 vs. 6.80 ± 2.41 (p = 0.27). Liver stiffness decrease was more significant in patients with initially higher transaminases. Undetectable viral load was achieved in 73.5% of patients in year one, 82.7% in year two, and 90.8% in year three of treatment. In conclusion, our study reveals a decrease in liver stiffness by TE in patients with chronic hepatitis B when undergoing anti-HBV therapy in the first two years. It can be used as a method for follow-up in patients undergoing NUC therapy.

Liver Fibrosis Assessment Using Transient Elastography by FibroScan and Shear Wave Elastography by Sonography: A Comparative Cross-sectional Study in an Outpatient Liver Clinic

Background: Non-alcoholic fatty liver disease (NAFLD) is the second most common cause of liver transplantation in the United States, with a continuously growing prevalence. There are several non-invasive methods to detect liver fibrosis, which is defined as the accumulation of extracellular matrix proteins, particularly collagens. It is most commonly associated with chronic liver diseases, such as NAFLD. Objectives: This study aimed to investigate the concordance between transient elastography (TE) and shear wave elastography (SWE) for liver fibrosis staging and also to examine the congruence between the controlled attenuation parameter (CAP) and the B-mode hepatorenal ratio for hepatic steatosis grading in patients with NAFLD. Patients and Methods: In this cross-sectional study conducted during March 2018 - 2019, NAFLD patients, referred to the liver clinic of our center for the non-invasive assessment of hepatic fibrosis, were enrolled. However, patients with sonographic features of cirrhosis, multiple hepatic masses, or moderate to large ascites were excluded; also, patients who were uncooperative during the tests were excluded. Measurements obtained by different tools were recorded. Kolmogorov-Smirnov test, Chi-square test, independent t-test, or Mann-Whitney tests, as well as Pearson’s correlation coefficient test, were used to analyze the data. Results: Sixty-five patients (male-to-female ratio, 1:13), with a median age of 47 years, were included in the study. The tools for assessing fibrosis (r = 0.9538, 95% CI: 0.9252 - 0.9717, P < 0.0001) and steatosis (r = 0.429, 95% CI: 0.2048 - 0.6104, P < 0.0001) were perfectly and moderately correlated, respectively. Sex, age, and body mass index (BMI) did not affect the results. Conclusion: The two elastography modalities showed a strong correlation for fibrosis staging in our study population. Also, the CAP and B-mode hepatorenal ratio were moderately correlated for grading hepatosteatosis. Overall, selection of the best assessment method among the studied modalities depends on factors other than internal validity.

Effect of skin-capsular distance on controlled attenuation parameter for diagnosing liver steatosis in patients with nonalcoholic fatty liver disease

The effect of the skin-capsular distance (SCD) on the controlled attenuation parameter (CAP) for diagnosis of liver steatosis in patients with nonalcoholic fatty liver disease (NAFLD) remains unclear. The SCD was measured using B-mode ultrasound, and the CAP was measured using the M probe of FibroScan®. According to the indications of the M probe, 113 patients with an SCD of ≤ 25 mm were included in the present study. The association between the SCD and CAP was investigated, and the diagnostic performance of the SCD-adjusted CAP was tested. The SCD showed the most significant positive correlation with the CAP (ρ = 0.329, p < 0.001). In the multiple regression analysis, the SCD and serum albumin concentration were associated with the CAP, independent of pathological liver steatosis. According to the multivariate analysis, two different formulas were developed to obtain the adjusted CAP using the SCD and serum albumin concentration as follows: adjusted CAP (dB/m) = CAP - (5.26 × SCD) and adjusted CAP (dB/m) = CAP - (5.35 × SCD) - (25.77 × serum albumin concentration). The area under the receiver operating characteristic curve for diagnosis of a steatosis score ≥ 2 of adjusted CAP was 0.678 and 0.684 respectively, which were significantly greater than the original CAP (0.621: p = 0.030 and p = 0.024). The SCD is associated with the CAP independent of liver steatosis. Adjustment of the CAP using the SCD improves the diagnostic performance of the CAP in NAFLD.

Elastography Techniques for the Assessment of Liver Fibrosis in Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is expected to increase in prevalence because of the ongoing epidemics of obesity and diabetes, and it has become a major cause of chronic liver disease worldwide. Liver fibrosis is associated with long-term outcomes in patients with NAFLD. Liver biopsy is recommended as the gold standard method for the staging of liver fibrosis. However, it has several problems. Therefore, simple and noninvasive methods for the diagnosis and staging of liver fibrosis are urgently needed in place of biopsy. This review discusses recent studies of elastography techniques (vibration-controlled transient elastography, point shear wave elastography, two-dimensional shear wave elastography, and magnetic resonance elastography) that can be used for the assessment of liver fibrosis in patients with NAFLD.

Ultrasound-guided transient elastography and two-dimensional shear wave elastography for assessment of liver fibrosis: emphasis on technical success and reliable measurements

Purpose

This study investigated whether the use of ultrasound (US) guidance in transient elastography (TE) improved the technical success and reliability of liver stiffness (LS) measurements and whether 2-dimensional (2D) shear wave elastography (SWE) provided reliable LS measurements if TE measurements failed.

Methods

In this prospective study, 292 participants (male:female, 189:103; median age, 60 years) with chronic liver disease (CLD) were enrolled. LS was measured via the consecutive use of conventional TE, 2D-SWE, and US-guided TE. The technical success rates and reliable LS measurement rates of the three elastography techniques were compared. The risk factors for TE failure were assessed through univariate and multivariate logistic regression models.

Results

US-guided TE was associated with a higher technical success rate (281 of 292, 96.2%) and a higher reliable measurement rate (266 of 292, 91.1%) than conventional TE (technical success: 256 of 292, 87.7%; reliable measurements: 231 of 292, 79.1%; P<0.001 for both). In participants for whom conventional TE failed, 2D-SWE provided high rates of technical success (36 of 36, 100%) and reliable measurements (30 of 36, 83.3%). TE failure was associated with female sex (odds ratio [OR], 5.85; 95% confidence interval [CI], 1.30 to 26.40), severe reverberation artifacts (OR, 8.79; 95% CI, 3.93 to 19.69), and high skin-to-liver capsule depth (OR, 1.23; 95% CI, 1.09 to 1.39).

Conclusion

US guidance in TE improved the technical success and reliable measurement rates in the assessment of LS in patients with CLD. In participants for whom TE failed, subsequent 2D-SWE successfully delivered reliable LS measurements.

Optimizing the Use of the Gamma-Glutamyl Transpeptidase-to-Platelet Ratio and Transient Elastography to Identify Liver Cirrhosis in Patients with Chronic Hepatitis B Concurrent with Nonalcoholic Fatty Liver Disease

Background and Aim

Little information is available about the assessment and optimal use of the gamma-glutamyl transpeptidase-to-platelet ratio (GPR) and transient elastography (TE) in predicting liver cirrhosis in patients with chronic hepatitis B (CHB) and concurrent nonalcoholic fatty liver disease (NAFLD). This study is aimed at comparing their diagnostic performances and developing an optimal approach for predicting liver cirrhosis in CHB patients with NAFLD.

Methods

Consecutive CHB patients with NAFLD were enrolled. The GPR was calculated, and TE was performed using liver biopsy as a reference standard. The accuracy of predicting liver cirrhosis using GPR and TE was assessed and compared, and an optimal approach was developed.

Results

Both TE and GPR correlated significantly with the histological fibrosis stage. TE and GPR had excellent performance in predicting liver cirrhosis, and the comparison of areas under the receiver operating characteristic curves revealed that TE was superior to GPR (0.95 vs. 0.85, P = 0.039). Moreover, the dual cutoffs established by the likelihood ratio showed that GPR had a similar misclassification but higher indeterminate rate than TE (54.5% vs. 11.7%, P < 0.001). Additionally, a 2-step approach using GPR followed by TE had comparable performance to that of both GPR and TE tests for all patients (misclassification: 8.9% vs. 8.3%, P = 0.866; indeterminate rate: 15.2% vs. 17.2%, P = 0.750) but could reduce TE scans by approximately one-third.

Conclusions

Both TE and GPR show excellent performance in predicting liver cirrhosis in CHB patients with NAFLD. The 2-step approach using GPR followed by TE may be optimal for the assessment of cirrhosis in CHB patients with NAFLD.

Assessment of Hepatic Steatosis in Patients with Chronic Hepatitis B Using Fibroscan and its Relation to Insulin Resistance

Background & Aim:

Simple hepatic steatosis is a benign condition, but it may cause serious liver damage as it may lead to steatohepatitis, fibrosis and cirrhosis. The Controlled Attenuation Parameter (CAP) of fibroscan assesses hepatic steatosis. The aim of this work was to assess hepatic steatosis in patients with chronic hepatitis B infection using FibroScan and to detect its relation to insulin resistance.

Methods:

Seventy-seven patients with chronic HBV were enrolled in this study. Body mass index, complete lipid profile, fasting insulin, HOMA-IR, pelviabdominal ultrasound and fibroscan were assessed in all patients.

Results:

According to the presence of significant steatosis, seventy-seven patients enrolled in this study were divided into different groups, such as group I 47 patients (61.04%) with CHB virus infection with non-significant steatosis and group II 30 patients (38.96%) with CHB infection with significant steatosis. There was a statistically significant increase in fasting insulin and HOMA-IR in group II (p-value <0.001). CAP results ranged from 100-396 db/m with no significant difference in liver stiffness measurements in two studied groups (P value= 0.886). There was a significant positive correlation between the degree of hepatic steatosis measured by fibroscan and fasting insulin blood level, HOMA-IR, serum cholesterol and LDL. At cutoff > 222 db/m steatosis measured by fibroscan had a sensitivity of 63.33% and specificity of 82.35% for the detection of insulin resistance.

Conclusion:

In CHB infected patients, steatosis measurement by fibroscan was a strong predictor of Insulin Resistance (IR) and vice versa.

Abdominal Wall Thickness Affects Liver Stiffness Measurements by 2-D Shear Wave Elastography in Patients with Chronic Liver Disease

This study was conducted to define the effect of abdominal wall thickness (AWT) and its composition on the level of confidence in liver stiffness (LS) measurements obtained with 2-D shear wave elastography (2-D-SWE) in patients with chronic liver disease. In this retrospective study, a total of 1291 patients who underwent LS measurement by 2-D-SWE were enrolled. The abdominal wall was divided into three layers: layer 1 extended from the skin to the subcutaneous fat layer; layer 2 was the muscle layer; and layer 3 extended from the peritoneum to the liver capsule (including the omental fat layer, if present). We regarded the sums of layers 1-3 and layers 1 and 3 as the AWT and non-muscular layer thickness (NMT). Age/sex/body mass index-adjusted multivariate logistic regression analysis was performed to identify factors influencing the level of confidence of LS measurements. Three hundred eighty-six patients (29.9%) were classified in the unreliable LS group (standard deviation/median LS > 0.1). The fourth quartile of AWT and third and fourth quartiles of NMT/AWT were significantly associated with unreliable LS values (odds ratios = 2.103, 1.753 and 1.695, respectively). In conclusion, high AWT and NMT/AWT ratios reduce the confidence in LS measurements obtained with 2-D-SWE.

Prospective comparison of 2D-shearwave elastography in both liver lobes in healthy subjects and in patients with chronic liver disease

Background/aims: 2D-shearwave elastography is an established method for liver stiffness measurement (LSM). However, the success rate of LSM using the recommended standard technique in the right lobe is limited by several factors. We aimed to compare LSM in the right and left liver lobe in order to evaluate whether LSM in the left lobe could be an alternative if measurements in the right lobe are not feasible. Methods: A total of 116 subjects, 58 healthy volunteers and 58 patients with chronic liver disease (CLD), were prospectively included. LSM were performed in the right lobe and in the left lobe, both in neutral and in inspiration position. Results: LSM in the left lobe (8.39(±4.83)kPa) was significantly (p < .001) higher than LSM in the right lobe (6.27(±2.45)kPa). LSM in inspiration position (8.60(±4.33) kPa) was significantly (p = .009) higher than LSM in neutral position (7.70(±3.01)kPa). LSM in the left lobe overestimated the grade of fibrosis in 50.0% of the patients with CLD. However, correlation between LSM values right and left was strong (r = 0.856) and additional use of LSM in the left lobe increased the success rate from 106/116 (91.4%) to 112/116 (96.6%; p = .098). High skin-to-liver-capsule-distance and presence of ascites were independent risk factors for non-successful LSM. Conclusions: Despite significantly higher values, LSM in the left lobe may be an alternative if LSM in the right lobe is not feasible, and cirrhosis can be ruled out with high probability if LSM is within the normal range.

Transient Elastography and Ultrasonography: Optimal Evaluation of Liver Fibrosis and Cirrhosis in Patients with Chronic Hepatitis B Concurrent with Nonalcoholic Fatty Liver Disease

Background and Aims

Concordance between transient elastography (TE) and ultrasonography (US) in assessing liver fibrosis in patients with chronic hepatitis B (CHB) and concurrent nonalcoholic fatty liver disease (NAFLD) has been rarely studied. This study aimed to evaluate the individual and combined performances of TE and US in assessing liver fibrosis and cirrhosis.

Patients and Methods

Consecutive CHB patients with NAFLD were prospectively enrolled. TE and US examinations were performed, with liver biopsy as a reference standard. Receiver operating characteristic (ROC) curves were obtained to evaluate the diagnostic performance. Differences between the areas under the ROC curves (AUCs) were compared using DeLong's test.

Results

TE and US scores correlated significantly with the histological fibrosis staging scores. TE was significantly superior to US in the diagnosis of significant fibrosis (AUC, 0.84 vs 0.73; P=0.02), advanced fibrosis (AUC, 0.95 vs 0.76; P<0.001), and cirrhosis (AUC, 0.96 vs 0.71; P<0.001). Combining TE with US did not increase the accuracy of detecting significant fibrosis, advanced cirrhosis, or cirrhosis (P=0.62, P=0.69, and P=0.38, respectively) compared to TE alone. However, TE combined with US significantly increased the positive predictive value for significant fibrosis when compared to TE alone. The optimal cut-off values of TE for predicting advanced fibrosis and cirrhosis were 8.7 kPa and 10.9 kPa, with negative predictive values of 92.4% and 98.7%, respectively.

Conclusions

TE is useful for predicting hepatic fibrosis and excluding cirrhosis in CHB patients with NAFLD. A combination of TE and US does not improve the accuracy in assessing liver fibrosis or cirrhosis.

Feasibility and Efficacy of Transient Elastography using the XL probe to diagnose liver fibrosis and cirrhosis: A meta-analysis

BACKGROUND

Transient elastography (TE) has been validated as an effective noninvasive tool for the assessment of liver fibrosis. The XL probe is a new probe that was initially designed for use in patients with obesity. A meta-analysis was performed to assess the feasibility and efficacy of TE using the XL probe.

METHODS

In September 2016, we systematically searched the PubMed and Science Direct search engines. The feasibility of TE was evaluated based on the failure rate and the results of the unreliable liver stiffness measurement (LSM). The efficacy of TE was measured using sensitivity, specificity, and summary receiver-operating characteristic as measures/indices assessed in different stages of fibrosis. Heterogeneity was measured using the chi-squared test and the Q-statistic. We used the 95% confidence interval (95% CI) as an effect measure.

RESULTS

We included 8 studies in the meta-analysis. When the XL was compared to the M probe, the former showed a lower risk of failure rate [relative risk (RR) 0.24, 95% CI 0.14-0.38]. In patients with a body mass index ≥30 kg/m, the XL probe showed a statistically significantly lower risk of failure rate (RR 0.16, 95% CI 0.08-0.32) but no significant improvement (RR 0.76, 95% CI 0.50-1.16) in the unreliable LSM result. In patients showing liver fibrosis stage ≥F2, the XL probe showed a sensitivity of 0.56 (95% CI 0.39-0.72), specificity of 0.71 (95% CI 0.61-0.79), and an area under the curve (AUC) of 0.71. The results observed in patients with liver fibrosis stage F4 were more promising with a sensitivity of 0.84 (95% CI 0.76-0.90), specificity of 0.78 (95% CI 0.70-0.84), and an AUC of 0.88.

CONCLUSION

TE using the XL probe demonstrates significant diagnostic utility in patients with liver fibrosis and is likely to be more reliable than the M probe in patients with obesity. Large prospective multicenter studies are, however, necessary to establish the new cut-off values to be used for the XL probe in patients with obesity.

Accuracy of 2D shear wave elastography in the diagnosis of liver fibrosis in patients with chronic hepatitis C

PURPOSE

This prospective study was conducted to assess the diagnostic accuracy of two-dimensional shear wave elastography (2D SWE) in the diagnosis of liver fibrosis in patients with chronic liver disease and hepatitis C virus (HCV) compared with the serum liver fibrosis biomarkers using the results of liver biopsy as the reference standard.

METHODS

We analyzed 233 consecutive HCV patients. On the same day, 2D SWE m, biochemical tests, and liver biopsy were performed. We used the METAVIR staging system and receiver operating characteristic curves for the analysis.

RESULTS

The success rate of 2D-SWE was 98.7%. The median shear wave velocities (SWVs) of patients in the F0, F1, F2, F3, and F4 stages were 1.35 m/s, 1.42 m/s, 1.58 m/s, 1.83 m/s, and 2.13 m/s, respectively, demonstrating a stepwise increase (P < .0001). The accuracy of 2D-SWE in the prediction of ≥F1, ≥F2, ≥F3, and F4 was .888 (95% CI: .85-.93), .915 (95% CI: .88-095), .940 (95% CI: .91-.97), and .949 (95% CI: .92-.97), respectively. 2D-SWE was significantly superior to serum liver fibrosis biomarkers.

CONCLUSION

2D-SWE was positively correlated with the severity of liver fibrosis and was more useful for to predict all liver fibrosis grades in HCV patients than liver fibrosis biomarkers.

Ultrasonography for Noninvasive Assessment of Portal Hypertension

Portal hypertension is a major pathophysiology in patients with cirrhosis. Portal pressure is the gold standard to evaluate the severity of portal hypertension, and radiological intervention is the only procedure for pressure measurement. Ultrasound (US) is a simple and noninvasive imaging modality available worldwide. B-mode imaging allows broad applications for patients to detect and characterize chronic liver diseases and focal hepatic lesions. The Doppler technique offers real-time observation of blood flow with qualitative and quantitative assessments, and the application of microbubble-based contrast agents has improved the detectability of peripheral blood flow. In addition, elastography for the liver and spleen covers a wider field beyond the original purpose of fibrosis assessment. These developments enhance the practical use of US in the evaluation of portal hemodynamic abnormalities. This article reviews the recent progress of US in the assessment of portal hypertension.

Diverse correlations between fibrosis-related factors and liver stiffness measurement by transient elastography in chronic hepatitis B

BACKGROUND

Several fibrosis-related factors influence liver stiffness measurements (LSM); however, these changes have not been investigated in the context of the various disease stages of chronic hepatitis B (CHB).

AIM

The aim of this study was to assess the correlations between fibrosis-related factors and LSM in different disease stages of CHB.

PATIENTS AND METHODS

Patients with mild CHB (n=305) and cirrhotic hepatitis B (cirrhotic HB) (n=137) were compared with determine the relationship between LSM and fibrosis-related factors including parameters of liver inflammation [aminotransferase (ALT), aspartate transaminase (AST), total bilirubin (Tbil)], albumin, globulin, peripheral blood cells (neutrophil granulocytes, red blood cells, platelets), abdominal ultrasound B-scan parameters including right liver thickness, portal vein inradium, diameter of spleen (DS), thickness of spleen (TS), and splenic vein inradium (SV).

RESULTS

In patients with mild CHB, LSM was correlated strongly with ALT (r=0.3534, P<0.0001), AST (r=0.3976, P<0.0001), and ALT+AST (r=0.3760, P<0.0001). LSM was correlated closely with Tbil (r=0.2237, P<0.0001), albumin (r=-0.3126, P<0.0001), albumin/globulin (r=-0.3086, P<0.0001), SV (r=0.3317, P<0.0001), DS (r=0.4157, P<0.0001), and spleen volume (DS×TS) (r=-0.4399, P<0.0001). Red blood cells were correlated negatively with LSM in both mild CHB and cirrhotic HB patients (r=-0.1981, P=0.0203; r=-0.1593, P=0.0053). LSM was not correlated with age, peripheral blood cell parameters, right liver thickness, portal vein inradium, or TS in mild CHB or cirrhosis HB patients. However, in patients with cirrhotic HB, LSM values were not correlated significantly with other fibrosis-related factors, except for Tbil (r=0.2272, P=0.0076).

CONCLUSION

Our findings suggest that the magnitude of these correlations differs significantly between mild CHB and cirrhotic HB patients.

Clinical strategy of diagnosing and following patients with nonalcoholic fatty liver disease based on invasive and noninvasive methods

Nonalcoholic fatty liver disease (NAFLD) is an important cause of chronic liver injury in many countries. The incidence of NAFLD is rising rapidly in both adults and children, because of the currently ongoing epidemics of obesity and type 2 diabetes. Notably, histological liver fibrosis is recognized as the main predictive factor for the overall long-term outcome of NAFLD, including cardiovascular disease and liver-related mortality. Thus, staging of liver fibrosis is essential in determining the prognosis and optimal treatment for patients with NAFLD and in guiding surveillance for the development of hepatocellular carcinoma (HCC). Whereas liver biopsy remains the gold standard for staging liver fibrosis, it is impossible to enforce liver biopsy in all patients with NAFLD. Noninvasive biological markers, scoring systems and noninvasive modalities are increasingly being developed and investigated to evaluate fibrosis stage of NAFLD patients. This review will highlight recent studies on the diagnosis and staging of NAFLD based on invasive (liver biopsy) or noninvasive (biomarker, scoring systems, US-based elastography and MR elastography) methods.

American Gastroenterological Association Institute Technical Review on the Role of Elastography in Chronic Liver Diseases

Chronic liver diseases (CLDs), due to chronic hepatitis C; hepatitis B; nonalcoholic fatty liver diseases (NAFLD); and alcoholic liver disease, are a leading cause of morbidity and mortality globally. Early identification of patients with cirrhosis at high risk of progression to liver-related complications may facilitate timely care and improve outcomes. With risks and misclassification associated with invasive tests, such as liver biopsy, noninvasive imaging modalities for liver fibrosis assessment have gained popularity. Therefore, the American Gastroenterological Association prioritized clinical guidelines on the role of elastography in CLDs, focusing on vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). To inform these clinical guidelines, the current technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for diagnostic accuracy studies. This technical review addresses focused questions related to: (1) comparative diagnostic performance of VCTE and MRE relative to nonproprietary, serum-based fibrosis markers for detection of cirrhosis in patients with hepatitis C virus (HCV), hepatitis B virus (HBV), NAFLD, and alcoholic liver diseases; (2) performance of specific VCTE-defined liver stiffness cutoffs as a test replacement strategy (to replace liver biopsy) in making key decisions in the management of patients with CLDs; and (3) performance of specific VCTE-defined liver stiffness cutoffs as a triage test to identify patients with low likelihood of harboring high-risk esophageal varices (EVs) or having clinically significant portal hypertension (for presurgical risk stratification). This technical review does not address performance of other noninvasive modalities for assessing fibrosis (eg, acoustic radiation force pulse imaging or shear wave elastography) or steatosis (controlled attenuation parameter or magnetic resonance imaging-estimated proton density fat fraction).

Two-dimensional shear wave elastography with propagation-based reliability assessment for grading hepatic fibrosis and portal hypertension

BACKGROUND

The aim of the present study was to examine the diagnostic ability of two-dimensional shear wave elastography (2D-SWE) with propagation-based reliability for grading of hepatic fibrosis and portal hypertension.

METHODS

This prospective study (UMIN000022838) consisted of 135 subjects. Phase I (n = 40) examined the effect of standard deviation (SD)/median as the reliability criterion of 2D-SWE, and phase II (n = 95) compared the diagnostic ability of 2D-SWE under the best SD/median value and transient elastography (TE).

RESULTS

Phase I reported 0.49 as a best cut-off SD/median value. In phase II, the elasticity showed a correlation between the 2D-SWE and TE (r = 0.88, P < 0.001). The area under the receiver operating characteristic curve (AUROC) was comparable between the 2D-SWE and TE (0.936 and 0.948 for chronic hepatitis, P = 0.34; 0.939 and 0.956 for cirrhosis, P = 0.25). The hepatic venous pressure gradient showed a positive correlation with the 2D-SWE (r = 0.435, P = 0.043) and TE (r = 0.378, P = 0.083) in 22 patients. The AUROC was comparable between the 2D-SWE (0.844 for ≥10 mmHg, 0.838 for ≥12 mmHg) and TE (0.781 for ≥10 mmHg, P = 0.484; 0.800 for ≥12 mmHg, P = 0.589).

CONCLUSIONS

2D-SWE is promising for the assessment of the grade of hepatic fibrosis and portal hypertension, with the SD/median value as a reliability criterion.

Appropriate use of virtual touch quantification and FibroScan M and XL probes according to the skin capsular distance

BACKGROUND

Appropriate utilization of different diagnostic modalities is essential for the accurate liver stiffness measurements (LSM) in patients with chronic liver diseases. The aim of this study was to evaluate the efficacy of Virtual Touch Quantification (VTQ) and the FibroScan M and XL probes in term of accurate LSM and to identify factors associated with inadequate measurements in obese and non-obese Japanese patients.

METHODS

A total of 664 consecutive patients with chronic liver disease were prospectively enrolled. LSM were evaluated concurrently with VTQ and the FibroScan M and XL probes. LSM quality was categorized as inadequate (success rate <60% and/or interquartile range/median value of ≥30%) or adequate.

RESULTS

No significant differences in the rate of inadequate LSM were observed among the three diagnostic modalities. In multivariate analysis, skin capsule distance (SCD) was strongly associated with inadequate rates obtained with VTQ and the M probe [odds ratio (OR) 1.28, P < 0.0001 and OR 1.20, P < 0.0001, respectively]. Inadequate LSM rates with both VTQ and the M probe increased with longer SCD, with a significant difference between subgroups at an SCD of ≥22.5 mm (VTQ 54.0%; M probe 51.1%; XL probe 25.2%; P < 0.0001). The rates of inadequate LSM rates with VTQ were significantly lower than those with the XL probe at an SCD of <17.5 mm. A total of 15 liver biopsy specimens obtained from nonalcoholic fatty liver disease patients confirmed the diagnostic accuracy and high applicability of the XL probe.

CONCLUSIONS

Long SCD reduced the diagnostic performance of the FibroScan® M probe and VTQ. LSM modalities should be selected according to SCD.

Factors Influencing the Diagnostic Accuracy of Acoustic Radiation Force Impulse Elastography in Patients with Chronic Hepatitis B

BACKGROUND/AIMS

To determine factors predictive of discordance in staging liver fibrosis using liver biopsy (LB) and acoustic radiation force impulse (ARFI) elastography in patients with chronic hepatitis B (CHB).

METHODS

Consecutive patients with CHB who underwent LB and ARFI elastography on the same day from November 2010 to March 2013 were prospectively recruited from three tertiary hospitals.

RESULTS

We analyzed 105 patients (median age of 47 years). The F0-1, F2, F3, and F4 fibrosis stages were identified in 27 (25.7%), 27 (25.7%), 21 (20.0%), and 30 (28.6%) patients, respectively. The areas under the receiver operating characteristics curves for ARFI elastography in assessing ≥ F2, ≥ F3, and F4 was 0.814, 0.848, and 0.752, respectively. The discordance of at least one stage between LB and ARFI was observed in 68 patients (64.8%) and of at least two stages in 16 patients (15.2%). In a multivariate analysis, advanced fibrosis stage (F3-4) was the only factor that was negatively correlated with one-stage discordance (p=0.042). Moreover, advanced fibrosis stage was negatively (p=0.016) correlated and body mass index (BMI) was positively (p=0.006) correlated with two-stage discordance.

CONCLUSIONS

Advanced fibrosis stage (F3-4) was a predictor of nondiscordance between LB and ARFI elastography; BMI also influenced the accuracy of ARFI elastography.

Performance of 2-D shear wave elastography in liver fibrosis assessment compared with serologic tests and transient elastography in clinical routine

Liver stiffness values assessed with 2-D shear wave elastography (SWE), transient elastography (TE) and simple serologic tests were compared with respect to non-invasive assessment in a cohort of 127 consecutive patients with chronic liver diseases. The rate of reliable liver stiffness measurements was significantly higher with 2-D SWE than with TE: 99.2% versus 74.8%, p < 0.0001 (different reliability criteria used, according to current recommendations). In univariate analysis, liver stiffness measured with 2-D SWE correlated best with fibrosis stage estimated with TE (r = 0.699, p < 0.0001), followed by Forns score (r = 0.534, p < 0.0001) and King's score (r = 0.512, p < 0.0001). However, in multivariate analysis, only 2-D SWE-measured values remained correlated with fibrosis stage (p < 0.0001). The optimal 2-D SWE cutoff values for predicting significant fibrosis were 8.03 kPa for fibrosis stage ≥2 (area under the receiver operating characteristic curve = 0.832) and 13.1 kPa for fibrosis stage 4 (area under the receiver operating characteristic curve = 0.915), respectively. In conclusion, 2-D SWE can be used to obtain reliable liver stiffness measurements in almost all patients and performs very well in predicting the presence of liver cirrhosis.

Supersonic Shear Imaging and Transient Elastography With the XL Probe Accurately Detect Fibrosis in Overweight or Obese Patients With Chronic Liver Disease

BACKGROUND & AIMS

Assessment of the severity of liver fibrosis is an important step in evaluating patients with chronic liver disease and determining their prognosis. We compared liver stiffness measurements (LSMs) made by supersonic shear imaging (SSI) with those of transient elastography (TE)-XL for their ability to determine the degree of liver fibrosis in overweight or obese patients with chronic liver disease.

METHODS

We performed a prospective study of 258 patients with chronic hepatitis of different etiologies and a body mass index greater than 25, evaluated at the University of Miami from October 2013 to December 2014. Liver stiffness was measured using the TE-XL probe and SSI of the right and left lobes during the same clinic visit, and comparisons were made for fibrosis stage in 124 biopsy-proven patients. In addition, further analysis was performed on a subgroup of 102 chronic hepatitis C virus (HCV)-positive patients for whom biopsy data were available.

RESULTS

Reliable LSMs were obtained from 96.1%, 94.6%, and 72.1% of patients using the TE-XL probe, SSI of the right lobe, and SSI of the left lobe, respectively. TE-XL, SSI of the right lobe, and SSI of the left lobe detected severe fibrosis (fibrosis stages 3-4), with area under the receiver operating characteristic curve (AUROC) values of 0.955, 0.954, and 0.910, respectively, compared with results from histologic analysis for the 124 biopsy-proven patients included in the study; these values were 0.952, 0.949, and 0.917, respectively, for the 102 biopsy-proven patients with HCV infection. TE-XL, SSI of the right lobe, and SSI of the left lobe detected fibrosis stage 4 with AUROC values of 0.920, 0.930, and 0.910, respectively, compared with histologic analysis, in all 124-biopsy proven patients, and with AUROC values of 0.907, 0.914, and 0.887, respectively, in the 102 biopsy-proven patients with chronic HCV infection.

CONCLUSIONS

SSI and the TE-XL probe each accurately quantify liver fibrosis in overweight or obese patients with chronic liver disease, including those with HCV infection, when compared with data obtained from histologic analysis. SSI data obtained from the right lobe and the TE-XL probe can be used to evaluate fibrosis with similar accuracy.

New reliability criteria for transient elastography increase the number of accurate measurements for screening of cirrhosis and portal hypertension

BACKGROUND & AIMS

Transient elastography (TE) can non-invasively diagnose cirrhosis and portal hypertension (PHT). New TE reliability criteria suggest classifying measurements as very reliable (IQR/M < 0.1), reliable (IQR<0.3 or >0.3, if TE < 7.1 kPa) and poorly reliable (IQR/M > 0.3, if TE > 7.1 kPa). Compare traditional (reliable: success rate >60% + IQR/M ≤ 0.30) and new TE quality criteria (accurate: very reliable + reliable) regarding their diagnostic accuracy for cirrhosis and PHT and to identify potential confounders (age, aetiology, necroinflammatory activity, steatosis, siderosis, cholestasis, aminotransferases) of TE performance.

METHODS

Patients undergoing simultaneous measurements of TE, portal pressure (hepatic venous pressure gradient, HVPG) and liver biopsy were analysed.

RESULTS

Among 226 patients (48.7 ± 13.1 years, 74.7% male, 75.7% viral aetiology, 57% F3/F4), traditional TE quality criteria identified 71.6% reliable measurements, while new criteria yielded in 83.2% accurate results. Reliable TE values according to both criteria significantly correlated with fibrosis stage (r = 0.648 vs. r = 0.636) and HVPG (r = 0.836 vs. r = 0.846). Diagnostic accuracy for cirrhosis (cut-off >14.5 kPa) was 76.5% (AUC: 0.863) and 75.0% (AUC: 0.852) for traditional and new TE criteria, respectively, while for predicting HVPG ≥ 10 mmHg (>16.1 kPa), the accuracies were 88.9% (AUC: 0.957) and 89.8% (AUC: 0.962). New TE criteria allowed a better discrimination of reliable and non-reliable results for prediction of fibrosis and CSPH. Only aetiology and aminotransferases were independent confounders of the correlation of TE and fibrosis stage, while no confounder affected the correlation of TE and HVPG.

CONCLUSIONS

New reliability criteria for TE measurements increase the number of patients with accurate measurements without affecting diagnostic performance for detecting cirrhosis and portal hypertension. Aetiology of liver disease and aminotransferases should be considered when assessing liver fibrosis by TE.

Which are the cut-off values of 2D-Shear Wave Elastography (2D-SWE) liver stiffness measurements predicting different stages of liver fibrosis, considering Transient Elastography (TE) as the reference method?

INTRODUCTION

To identify liver stiffness (LS) cut-off values assessed by means of 2D-Shear Wave Elastography (2D-SWE) for predicting different stages of liver fibrosis, considering Transient Elastography (TE) as the reference method.

METHODS

Our prospective study included 383 consecutive subjects, with or without hepatopathies, in which LS was evaluated by means of TE and 2D-SWE. To discriminate between various stages of fibrosis by TE we used the following LS cut-offs (kPa): F1-6, F2-7.2, F3-9.6 and F4-14.5.

RESULTS

The rate of reliable LS measurements was similar for TE and 2D-SWE: 73.9% vs. 79.9%, p=0.06. Older age and higher BMI were associated for both TE and 2D-SWE with the impossibility to obtain reliable LS measurements. Reliable LS measurements by both elastographic methods were obtained in 65.2% of patients. A significant correlation was found between TE and 2D-SWE measurements (r=0.68). The best LS cut-off values assessed by 2D-SWE for predicting different stages of liver fibrosis were: F≥1: >7.1 kPa (AUROC=0.825); F≥2: >7.8 kPa (AUROC=0.859); F≥3: >8 kPa (AUROC=0.897) and for F=4: >11.5 kPa (AUROC=0.914).

CONCLUSIONS

2D-SWE is a reliable method for the non-invasive evaluation of liver fibrosis, considering TE as the reference method. The accuracy of 2D-SWE measurements increased with the severity of liver fibrosis.

Factors associated with the impossibility to obtain reliable liver stiffness measurements by means of Acoustic Radiation Force Impulse (ARFI) elastography--analysis of a cohort of 1,031 subjects

INTRODUCTION

Acoustic Radiation Force Impulse (ARFI) elastography is a non-invasive technique for liver fibrosis assessment.

AIM

To assess the feasibility of ARFI elastography in a large cohort of subjects and to identify factors associated with impossibility to obtain reliable liver stiffness (LS) measurements by means of this technique.

METHODS

Our retrospective study included 1031 adult subjects with or without chronic liver disease. In each subject LS was assessed by means of ARFI elastography. Failure of ARFI measurements was defined if no valid measurement was obtained after at least 10 shots and unreliable in the following situations: fewer than 10 valid shots; or median value of 10 valid measurements with a success rate (SR)<60% and/or an interquartile range interval (IQR) ≥ 30%.

RESULTS

Failure of LS measurements by means of ARFI was observed in 4 subjects (0.3%), unreliable measurements in 66 subjects (6.4%), so reliable measurements were obtained in 961 subjects (93.3%). In univariant analysis, the following risk factors were associated with failed and unreliable measurements: age over 58 years (OR=0.49; 95% CI 0.30-0.80, p=0.005), male gender (OR=0.58; 95% CI 0.34-0.94, p=0.04), BMI>27.7 kg/m(2) (OR=0.23, 95% CI 0.13-0.41, p<0.0001). In multivariate analysis all the factors mentioned above were independently associated with the risk of failed and unreliable measurements.

CONCLUSIONS

Reliable LS measurements by means of ARFI elastography were obtained in 93.3% of cases. Older age, higher BMI and male gender were associated with the risk of failed and unreliable measurements, but their influence is limited as compared with Transient Elastography.