FibroScan-AST (FAST) Score for Nonalcoholic Steatohepatitis - Validation in an Indian Cohort

Validation of the diagnostic accuracy of the acFibroMASH index for at-risk MASH in patients with metabolic dysfunction-associated steatotic liver disease

OBJECTIVE

The objective of this study was to validate the diagnostic accuracy of the acFibroMASH index in a population of metabolic dysfunction-associated steatotic liver disease (MASLD) patients with at-risk metabolic dysfunction-associated steatohepatitis (MASH) and to compare it with other scoring systems.

METHODS

394 patients with biopsy-proven MASLD were retrospectively enrolled. The patients were divided into the at-risk MASH (NAFLD activity score ≥ 4 and significant fibrosis) group (n = 103) and the non-at-risk MASH group (n = 291). The diagnostic performance of the acFibroMASH index was compared to that of fibroScan-aspartate aminotransferase (FAST) and other noninvasive fibrosis scores by plotting the receiver operating characteristic curve (ROC), including the area under the curve (AUC), sensitivity, and specificity. Cut-offs of the acFibroMASH index for sensitivity (≥ 0.90) and specificity (≥ 0.90) were obtained in our cohort.

RESULTS

The AUC of the acFibroMASH index in assessing at-risk MASH was 0.780, while the AUC of FAST was 0.770. The comparison of acFibroMASH with FAST showed no significant difference (P = 0.542). When the cut-off value for acFibroMASH was < 0.15, 95.5% of at-risk MASH patients could be excluded in 89 patients correctly. Conversely, when the cut-off value was set at > 0.39, 49.3% of at-risk MASH patients could be diagnosed in 140 patients correctly. When the NPV was set at 0.900, the critical value for exclusion was determined to be 0.23, with a sensitivity of 0.835 and a specificity of 0.526.

CONCLUSION

This study validated the efficacy of the acFibroMASH index in predicting at-risk MASH in a population of MASLD patients, demonstrating comparable performance to that of the FAST. The acFibroMASH index may provide a valuable clinical basis for screening and identifying at-risk MASH in primary care settings.

Waist circumference as a predictor for severity of liver fibrosis in non-alcoholic fatty liver disease patients

Introduction

Non-alcoholic fatty liver disease (NAFLD) may in some cases progress to increasing grades of liver fibrosis and eventually cirrhosis. NAFLD patients often succumb to cardiovascular causes. Previous studies have linked visceral fat, a known cardiovascular risk factor, to NAFLD. Visceral fat is best quantified by measuring the waist circumference (WC). This study is aimed to determine the association of waist circumference with severity of liver fibrosis in NAFLD patients.

Methods

In this cross-sectional study we recruited 82 NAFLD patients diagnosed via ultrasonography. They underwent anthropometric examination followed by transient elastography with Fibro Scan to assess of liver stiffness measure (LSM). A cutoff LSM value of 7kPa was used to indicate significant fibrosis. Among the participants, 40 patients had an LSM value of <7 kPa (insignificant/no fibrosis), while 42 were found to have >7 kPa (significant fibrosis). Biochemical parameters of Lipid profile and Liver enzymes were also analyzed.

Statistical Analysis Used

SPSS software with Student t-test, Chi-square t-test, ANOVA, and Spearman correlation with 95% CI is used. P <0.05 is considered significant.

Results

Patients with significant fibrosis had higher mean weight (P < 0.001), BMI (P = 0.009), WC (P = 0.002), and waist-hip ratio (WHR, P = 0.032) compared to those with no fibrosis. However, hip circumference (HC) was not significantly associated between the two groups. In correlation studies, BMI (P = 0.001), weight (P < 0.001), WC (P = 0.001), and HC (P = 0.008) positively correlated with severity of liver fibrosis in NAFLD patients. However, no significant correlation was found with WHR.

Conclusion

Weight, BMI, and visceral fat indicators like WC and WHR are strongly associated with liver fibrosis severity in NAFLD patients. Notably, weight, BMI, WC, and HC positively correlate with fibrosis severity, while WHR does not. Early diagnosis of fatty liver is crucial to prevent progression to life-threatening conditions like NASH or NASH cirrhosis. Waist circumference could serve as a practical screening tool in primary health care centres for identifying NAFLD patients at risk of fibrosis progression.

Fast score is associated with patient-reported outcomes in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUNDS

People with metabolic dysfunction-associated steatotic liver disease (MASLD) frequently report fatigue. This symptom is associated with hepatic inflammation and fibrosis. FibroScan-aspartate aminotransferase (FAST) score is a noninvasive measurement tool that can be used to assess the severity of MASLD. We aimed to investigate the independent factors associated with patient-reported outcomes (PROs) including fatigue, and their FAST scores.

METHODS

We enrolled 116 patients with MASLD. PROs were assessed by the Chronic Liver Disease Questionnaire for nonalcoholic fatty liver disease (CLDQ-NAFLD), which consists of six domains including fatigue. Each domain score that was less than 6 was classified into the impairment group. A cutoff value of 0.67 in the FAST score was used to categorize a high or low FAST score. Independent factors associated with impaired PROs and fatigue were analyzed using logistic regression analysis and a graphical model.

RESULTS

For factor total, in the logistic regression analysis, the high FAST score was only identified as a negative independent factor for impaired total CLDQ-NAFLD (odds ratio: 5.9, 95% confidence interval: 1.11-31.20, P  = 0.034). The graphical model revealed that FAST score, BMI, and age directly interact with impaired total CLDQ-NAFLD. For fatigue, there was no statistically significant factor in the logistic regression analysis. The graphical model revealed that the FAST score, BMI, estimated glomerular filtration rate, and age directly interact with fatigue.

CONCLUSION

We found that the FAST score directly interacted with total CLDQ-NAFLD and the domain of fatigue. The FAST score may be a useful tool to assess impaired CLDQ-NAFLD.

FibroScan-AST score for diagnosing fibrotic MASH: A systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND AND AIM

Following the approval of the first agent for the management of metabolic dysfunction-associated steatohepatitis (MASH), identification of patients with fibrotic MASH (MASH with NAS ≥ 4 and fibrosis stage ≥ 2) is crucial. We assessed the performance of FibroScan-aspartate aminotransferase (AST) score (FAST) for ruling in/out fibrotic MASH.

METHODS

We searched Medline, Cochrane Library, Web of Science, Scopus, and gray literature sources up to January 11, 2024. Studies were eligible if they assessed the accuracy of FAST score for the detection of fibrotic MASH using biopsy as the reference standard at previously reported thresholds (FAST ≥ 0.67 for ruling-in and ≤ 0.35 for ruling-out fibrotic MASH). We calculated pooled sensitivity and specificity estimates for FAST thresholds alongside 95% confidence intervals following bivariate random- effects models. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

We included 16 studies with 8838 participants. A FAST score ≥ 0.67 yielded a pooled specificity of 0.87 (0.82-0.90) while a FAST score ≤ 0.35 yielded a summary sensitivity of 0.88 (0.83-0.91). At a prevalence of 30%, the positive predictive value for ruling-in fibrotic MASH was 60% while the negative predictive value for ruling-out the target condition was 91%. AST levels, cirrhosis prevalence, and number of pathologists reviewing biopsies were sources of heterogeneity among studies. The certainty of evidence was low to very low.

CONCLUSIONS

FAST score can be used as a triage test for ruling out fibrotic MASH. Nevertheless, its low positive predictive value necessitates sequential testing for ruling-in fibrotic MASH.

Modernizing metabolic dysfunction-associated steatotic liver disease diagnostics: the progressive shift from liver biopsy to noninvasive techniques

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health concern worldwide. Liver biopsy is the gold standard for diagnosing and staging MASLD, but it is invasive and carries associated risks. In recent years, there has been significant progress in developing noninvasive techniques for evaluation. This review article discusses briefly current available noninvasive assessments and the various liver biopsy techniques available for MASLD, including invasive techniques such as transjugular and transcutaneous needle biopsy, intraoperative/laparoscopic biopsy, and the evolving role of endoscopic ultrasound-guided biopsy. In addition to discussing the various biopsy techniques, we review the current state of knowledge on the histopathologic evaluation of MASLD, including the various scoring systems used to grade and stage the disease. We also explore current and alternative modalities for histopathologic evaluation, such as whole slide imaging and the utility of immunohistochemistry. Overall, this review article provides a comprehensive overview of the progress in liver biopsy techniques for MASLD and compares invasive and noninvasive modalities. However, beyond clinical trials, the practical application of liver biopsy may be limited, as ongoing advancements in noninvasive fibrosis assessments are expected to more effectively identify candidates for MASLD treatment in real-world settings.

The associations between fibrosis changes and liver-related events in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

The prognosis of metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with liver fibrosis. We investigated the associations between changes in liver stiffness measurement (LSM) over 3-year period and the development of cirrhosis or hepatocellular carcinoma (HCC) in patients with MASLD.

METHODS

This study involved patients with MASLD who underwent transient elastography at baseline and 3 years after baseline from 2012 to 2020. Low (L), indeterminate (I) and high (H) LSM values were classified as <8 kPa, 8-12 kPa and >12 kPa respectively.

RESULTS

Among 1738 patients, 150 (8.6%) were diagnosed with cirrhosis or HCC. The proportions of patients with L, I and H risk were 69.7%, 19.9% and 10.5% at baseline, and 78.8%, 12.8% and 8.4% at 3 years after baseline, respectively. The incidence rates of cirrhosis or HCC per 1000 person-years were 3.7 (95% confidence interval [CI], 2.4-5.5) in the L → L + I group, 23.9 (95% CI, 17.1-32.6) in the I → L + I group, 38.3 (95% CI, 22.3-61.3) in the H → L + I group, 62.5 (95% CI, 32.3-109.2) in the I → H group, 67.8 (95% CI, 18.5-173.6) in the L → H group and 93.9 (95% CI 70.1-123.1) in the H → H group. Two risk factors for the development of cirrhosis or HCC were LSM changes and low platelet counts.

CONCLUSION

LSM changes could predict clinical outcomes in patients with MASLD. Thus, it is important to monitor changes in the fibrotic burden by regular assessment of LSM values.

Lean Indian patients with non-alcoholic fatty liver disease (NAFLD) have less metabolic risk factors but similar liver disease severity as non-lean patients with NAFLD

INTRODUCTION

Although most patients with NAFLD are obese or overweight, some are lean with normal BMI. Our aim was to assess differences in clinicopathological profile and liver disease severity among lean and non-lean NAFLD.

METHODS

Data of 1040 NAFLD patients over last 10 years was analysed. BMI < 23 kg/m2 categorised lean patients. Non-invasive assessment of steatosis was done by ultrasound and controlled attenuation parameter (CAP) while fibrosis was assessed with FIB-4 and liver stiffness measurement (LSM). FibroScan-AST (FAST) score was used for non-invasive prediction of NASH with significant fibrosis. Histology was reported using NASH-CRN system.

RESULTS

149 (14.3%) patients were lean while 891 (85.7%) patients were non-lean. Diabetes mellitus [25 (16.7%) vs 152 (17.05%), p > 0.99], elevated triglycerides [81 (54.3%) vs 525 (58.9%), p = 0.33] and low HDL [71(47.6%) vs 479(53.7%), p = 0.18] were observed in a similar proportion. Lean patients were less likely to have central obesity [72 (48.3%) vs 788 (88.4%), p < 0.001], hypertension [16 (10.7%) vs 239(26.8%), p < 0.001] and metabolic syndrome [21 (14.09%) vs 290 (32.5%), p < 0.001]. No difference in steatosis assessment was noted using ultrasound (p = 0.55) or CAP (0.11). FAST [0.38 (0.18-0.66) vs 0.39 (0.27-0.73), p = 0.53], FIB-4 [1.08 (0.65-1.91) vs 1.09 (0.66-1.94), p = 0.94] and LSM [6.1 (4.8-7.9) vs 6.2 (4.7-8.6), p = 0.19) were similar. Liver biopsy was available in 149 patients [lean: 19 (12.7%), non-lean: 130 (87.3%)]. There was no difference in the number of patients with NASH [4 (21.05%) vs 20 (15.3%), p = 0.51], significant fibrosis [2 (10.5%) vs 32 (24.6%), p = 0.25] or advanced fibrosis [1 (5.26%) vs 18 (13.84%), p = 0.47].

CONCLUSION

Although metabolic co-morbidities are less common, there is no difference in liver disease severity among both groups.

Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.

How to Identify Advanced Fibrosis in Adult Patients with Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH) Using Ultrasound Elastography-A Review of the Literature and Proposed Multistep Approach

Non-alcoholic fatty liver disease (NAFLD), and its progressive form, non-alcoholic steatohepatitis (NASH), represent, nowadays, real challenges for the healthcare system. Liver fibrosis is the most important prognostic factor for NAFLD, and advanced fibrosis is associated with higher liver-related mortality rates. Therefore, the key issues in NAFLD are the differentiation of NASH from simple steatosis and identification of advanced hepatic fibrosis. We critically reviewed the ultrasound (US) elastography techniques for the quantitative characterization of fibrosis, steatosis, and inflammation in NAFLD and NASH, with a specific focus on how to differentiate advanced fibrosis in adult patients. Vibration-controlled transient elastography (VCTE) is still the most utilized and validated elastography method for liver fibrosis assessment. The recently developed point shear wave elastography (pSWE) and two-dimensional shear wave elastography (2D-SWE) techniques that use multiparametric approaches could bring essential improvements to diagnosis and risk stratification.

Diagnostic accuracy of FibroScan-AST (FAST) score for the non-invasive identification of patients with fibrotic non-alcoholic steatohepatitis: a systematic review and meta-analysis

OBJECTIVE

A simple combined score with liver stiffness, controlled attenuation parameter and serum aspartate aminotransferase (AST), the FibroScan-AST (FAST) score, has been proposed to non-invasively identify patients with fibrotic non-alcoholic steatohepatitis (NASH). We performed a systematic review and meta-analysis of published studies to evaluate the overall diagnostic accuracy of the FAST score in identifying patients with fibrotic NASH.

DESIGN

We systematically searched MEDLINE, Ovid Embase, Scopus and Cochrane Library electronic databases for full-text published articles in any language between 3 February 2020 and 30 April 2022. We included original articles that reported data for the calculation of sensitivity and specificity of the FAST score for identifying adult patients with fibrotic NASH adults, according to previously described rule-out (≤0.35) and rule-in (≥0.67) cut-offs.

RESULTS

We included 12 observational studies for a total of 5835 participants with biopsy-confirmed non-alcoholic fatty liver disease. The pooled prevalence of fibrotic NASH was 28% (95% CI 21% to 34%). The FAST score's pooled sensitivity was 89% (95% CI 82% to 93%), and the pooled specificity was 89% (95% CI 83% to 94%) according to the aforementioned rule-in/rule-out cut-offs. The negative predictive value and positive predictive value of the FAST score were 92% (95% CI 91% to 95%) and 65% (95% CI 53% to 68%), respectively. Subgroup analyses and influential bias analyses did not alter these findings.

CONCLUSION

The results of our meta-analysis show that the FAST score has a good performance for non-invasive diagnosis of fibrotic NASH. Therefore, this score can be used to efficiently identify patients who should be referred for a conclusive liver biopsy and/or consideration for treatment with emerging pharmacotherapies.

PROSPERO REGISTRATION NUMBER

CRD42022350945.

Work-up for Incidentally Detected NAFLD: How Far is It Worth?

The incidence of nonalcoholic fatty liver disease (NAFLD) has seen a steep rise in parallel with the global obesity and metabolic syndrome epidemic. The presence of NAFLD contributes to significant socioeconomic burden due to healthcare costs, progression of liver disease as non-alcoholic steatohepatitis (NASH), and later cirrhosis and hepatocellular carcinoma (HCC). With the advent of widely available imaging, it is also being detected as an incidental diagnosis in individuals with systemic disease like metabolic syndrome, diabetes, chronic cardiac disease, polycystic ovarian syndrome, etc. or in asymptomatic persons on presurgical evaluation or even annual health assessments. Gastroenterologists, hepatologists, physicians and surgeons need to be updated about the new diagnostic criteria of Metabolic (dysfunction)-associated fatty liver disease, noninvasive tests (NITs) of liver fibrosis, new tools of elastography, and identification of those with high-risk disease. In this review, we appraise the relevance of new diagnostic definitions, steatosis and fibrosis estimation tests, advanced imaging like magnetic resonance elastography and proton density fat fraction and discuss the diagnostic algorithm for incidentally detected NAFLD.

HOW TO CITE THIS ARTICLE

Mishra S, Bhujade H, Butt AS, et al. Work-up for Incidentally Detected NAFLD: How Far is It Worth? Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S26-S36.