Accuracy of FibroScan Controlled Attenuation Parameter and Liver Stiffness Measurement in Assessing Steatosis and Fibrosis in Patients With Nonalcoholic Fatty Liver Disease

There is a close link between steatohepatitis (NASH) and Type 2 diabetes (T2DM). Recently, the American Diabetes Association (ADA) recommended screening for NASH and advanced fibrosis in patients with diabetes and hepatic steatosis or elevated plasma alanine aminotransferase (ALT). This is because as many as ~30% to 40% may have NASH and ~10% to 15% advanced fibrosis. The role of hyperglycemia and the natural history of NASH in diabetes remain poorly understood, as well as which diagnostic algorithm or interventions are most cost‐effective. There is significant clinical inertia and most patients today are still not receiving adequate lifestyle intervention or pharmacological treatment with diabetes agents known to be effective against NASH. Lifestyle intervention improves steatohepatitis in proportion to the magnitude of weight loss, but this trend is not as consistent for regression of fibrosis. This limited success supports the need for concomitant pharmacological therapy. Pioglitazone has been shown to consistently induce resolution of NASH in both patients with or without diabetes in a total of 498 participants in five randomized controlled trials (RCTs), but with modest effects on liver fibrosis. Proof‐of‐concept studies suggest a potential role for GLP‐1RAs and SGLT2 inhibitors. Combination therapy is on the horizon. Treating diabetes and NASH with a combination of pioglitazone, GLP‐1RAs or SGLT2i, could be a cost‐effective strategy to treat both diseases while reducing their high cardiovascular risk. Future combination therapies will likely combine existing diabetes agents with novel NASH‐spechfic drugs under development. This review highlights current knowledge gaps and proposes future directions for the treatment of NASH in diabetes.

Section: The Challeng E Of D Iag Nos Ing Na S H In Patients With T2dmsupporting

confidence: 91%

A diabetologist’s perspective of non‐alcoholic steatohepatitis (NASH): Knowledge gaps and future directions

Cusi

2020

“…The calculated LSM cut‐off for diagnosis of cirrhosis in recently diagnosed WD patients of ≥9.9 kPa showed excellent sensitivity (100%) and specificity (83.3%) respectively. One could argue that this cut‐off is lower than cut‐offs reported in other aetiologies . The cut‐off for cirrhosis in chronic hepatitis C is not well–defined; values in the literature range between 10 and 17.6 kPa .…”

Section: Discussionmentioning

confidence: 83%

Non‐invasive diagnosis of cirrhosis and long‐term disease monitoring by transient elastography in patients with Wilson disease

Paternostro

Pfeiffenberger

Ferenci

et al. 2020

Background & Aims The value of liver stiffness measurement (LSM) by transient elastography (TE) for non‐invasive fibrosis staging and disease monitoring has not been established in patients with Wilson disease (WD). Methods Liver stiffness measurement by TE and non‐invasive fibrosis scores (APRI, FIB‐4) were analysed from 188 WD patients with liver biopsy (LBX). Longitudinal LSM was performed in 128 (68.1%) patients. Results One hundred and eighty‐eight patients (mean age: 35 ± 14 years, 54.8% women; 27.1% with histological cirrhosis) were studied. Forty‐four[23.4%] patients were recently diagnosed with WD, while 144[76.6%] were previously diagnosed (>1 year between LBX and LSM). Overall, LSM (11.3 vs 6.1 kPa, P < .001), APRI (0.72 vs 0.38, P < .001) and FIB‐4 (1.54 vs 0.89, P < .001) were higher in cirrhotic than in non‐cirrhotic patients. This was even more pronounced in recently diagnosed patients (35.2 kPa vs 6.4 kPa, P < .001). Accuracy for diagnosing cirrhosis at an LSM cut‐off ≥9.9 kPa was better in recently diagnosed (PPV: 74%, NPV: 100%) vs previously diagnosed (PPV: 53%, NPV: 82%) patients. Recently diagnosed patients had higher Area Under the Curve (AUC) for APRI (0.79 vs 0.61) and FIB‐4 (0.84 vs 0.65) than previously diagnosed patients. At APRI <1.5 and FIB‐4 <3.25 cirrhosis was ruled out with a specificity of 93% and 95% respectively. During a median follow‐up of 46 (24‐66) months, only 5.9% (5/85) of non‐cirrhotic WD patients showed progression to cirrhotic LSM values, while 30.8% (4/13) of cirrhotic WD patients showed LSM suggestive of cirrhosis regression. Conclusion TE‐based LSM ≥9.9 kPa accurately identifies cirrhosis in WD patients. Next to TE‐LSM <9.9 kPa, APRI <1.5 and FIB‐4 <3.25 values assist to non‐invasively rule out cirrhosis. LSM remains stable in most non‐cirrhotic patients on WD therapy, while one‐third of cirrhotic patients present clinically relevant decreases in LSM.

“…However, most of these studies used the M probe. Two recent multicentre prospective studies using the XL probe in large cohorts of NAFLD patients (around 400) in the UK and in the USA, confirmed these results with AUROCs of 0.80‐0.83 for advanced fibrosis and 0.89‐0.93 for cirrhosis. Interestingly, steatosis and the type of probe did not affect liver stiffness measurements.…”

Section: Performance Of Non‐invasive Tests For Detecting Advanced Fibmentioning

confidence: 73%

“…For instance the FibroTest® has been shown to have an excellent applicability (99%) whereas the applicability of TE is lower in obese patients when the regular probe is used (M) (around 80%) . However, recent studies in NAFLD patients have shown that TE applicability increased to 97% when the XL probe was used …”

Section: Available Non‐invasive Tests and Important Considerations Whmentioning

confidence: 99%

See 1 more Smart Citation

Non‐invasive tests for liver fibrosis in NAFLD: Creating pathways between primary healthcare and liver clinics

Castéra

2020

Despite affecting around one‐fourth of the general population worldwide, non‐alcoholic fatty liver disease (NAFLD) remains a largely under‐recognized disease in primary healthcare, with not more than 10% of patients diagnosed with NAFLD referred to specialists. The main challenge in clinical practice is the identification of those with advanced liver fibrosis or cirrhosis, as they are at the greatest risk of developing complications. Liver biopsy appears to be an unrealistic and unsuitable option because of the large number of high‐risk patients and the well‐known limitations of this technique. This has favoured the development of non‐invasive tests, which have been an area of intensive research in the past decade. Transient elastography, FIB‐4 and the NAFLD fibrosis score are the most extensively used and best validated tests, with summary AUROC values for detecting advanced fibrosis in NAFLD patients of 0.88, 0.84 and 0.84 respectively. Although much work remains to be done to establish cost‐effective strategies for the screening for advanced fibrosis, the sequential use of non‐invasive tests (serum biomarkers, then measurement of liver stiffness using transient elastography) appears to be the most promising strategy. The next step is to establish effective pathways in primary healthcare and/or diabetes clinics where most NAFLD patients are seen, to identify those who need to be referred to liver clinics for further assessment.