Feasibility of liver stiffness measurement in morbidly obese patients undergoing bariatric surgery using XL probe

Weiß, Johannes; Rau, Monika; Meertens, Jan; Hering, Ilona; Reichert, Lisa; Kudlich, Theodor; Koschker, Ann-Kathrin; Jurowich, Christian; Geier, Andreas

doi:10.1080/00365521.2016.1191084

Cited by 21 publications

(17 citation statements)

References 32 publications

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“…In previous NAFLD studies, LSM cut‐off values for advanced fibrosis using the M probe ranged from 8‐12 kPa, with 84%‐100% sensitivity and 83%‐97% specificity . Relatively few published data are available using the XL probe, in particular the appropriate cut‐off values for fibrosis and whether severe obesity and steatosis influence the reliability and accuracy of these measurements . Importantly, we found that, among 41 patients with LSM ≥8.2 kPa (40 required the XL probe), 85.4% had advanced fibrosis or cirrhosis on histology or imaging.…”

Section: Discussionmentioning

confidence: 64%

“…(32) Relatively few published data are available using the XL probe, in particular the appropriate cut-off values for fibrosis and whether severe obesity and steatosis influence the reliability and accuracy of these measurements. (33)(34)(35)(36)(37)(38) Importantly, we found that, among 41 patients with LSM ≥8.2 kPa (40 required the XL probe), 85.4% had advanced fibrosis or cirrhosis on histology or imaging. In contrast, only 2 of 18 patients with LSM <8.2 kPa who underwent liver biopsy had Brunt fibrosis stage F3 and none had cirrhosis.…”

Section: Discussionmentioning

confidence: 94%

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A Pragmatic Approach Identifies a High Rate of Nonalcoholic Fatty Liver Disease With Advanced Fibrosis in Diabetes Clinics and At‐Risk Populations in Primary Care

Patel

Hossain

Horsfall

et al. 2018

Hepatology Communications

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Noninvasive serum biomarkers (nonalcoholic fatty liver disease fibrosis score [NFS], fibrosis 4 score [FIB‐4], or enhanced liver fibrosis [ELF] test) are recommended as first‐line tools to determine the risk of advanced fibrosis in nonalcoholic fatty liver disease. We aimed to assess the utility of a pragmatic approach to screening for clinically significant fibrosis in primary care and diabetes clinics. We recruited 252 patients from an endocrine clinic or primary care facility. Anthropometric measurements, ELF test, ultrasound, and liver stiffness measurements (LSMs) were performed. Clinically significant fibrosis was defined as LSM ≥8.2 kPa or ELF ≥9.8. A subgroup of patients underwent liver biopsy (n = 48) or had imaging diagnostic of cirrhosis (n = 14). Patients were 57.3 ± 12.3 years old with a high prevalence of metabolic syndrome (84.5%), type 2 diabetes (82.5%), and body mass index (BMI) ≥40 kg/m2 (21.8%). LSM met quality criteria in 230 (91.3%) patients. NFS and FIB‐4 combined had a high negative predictive value (90.0%) for excluding LSM ≥8.2 kPa. However, 84.1% of patients had indeterminate or high NFS or FIB‐4 scores requiring further assessment. LSM ≥8.2 kPa and ELF ≥9.8 were present in 31.3% and 28.6% of patients, respectively. Following adjustment for age, BMI, sex, and presence of advanced fibrosis, older age was independently associated with ELF ≥9.8 (adjusted odds ratio, 1.14; 95% confidence interval, 1.06‐1.24), whereas increasing BMI was independently associated with LSM ≥8.2 kPa (adjusted odds ratio, 1.15; 95% confidence interval, 1.01‐1.30). Concordant LSM <8.2 kPa and ELF <9.8 and concordant LSM ≥8.2 kPa and ELF ≥9.8 had a high negative predictive value (91.7%) and positive predictive value (95.8%) for excluding and identifying clinically significant fibrosis, respectively. Conclusion: Simple scoring tools alone lack accuracy. LSM accuracy is influenced by severe obesity, whereas age impacts the ELF test. Further studies are required to confirm whether combining LSM and ELF may enhance accuracy and confidence in identifying clinically significant fibrosis. (Hepatology Communications 2018; 00:000‐000)

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Section: Discussionmentioning

confidence: 64%

Section: Discussionmentioning

confidence: 94%

A Pragmatic Approach Identifies a High Rate of Nonalcoholic Fatty Liver Disease With Advanced Fibrosis in Diabetes Clinics and At‐Risk Populations in Primary Care

Patel

Hossain

Horsfall

et al. 2018

Hepatology Communications

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“…The second major finding in our study was that TE measurements correlated strongly with fibrosis when using the M probe but were unreliable when using the XL probe. Based on existing literature, we believe that BMI differences between groups are likely to explain this observation, where reduced penetration of TE shear waves into the intrahepatic tissue reduces performance of the test [21]. Indeed, a prospective study of more than 10,000 patients indicated that liver stiffness measurements are unreliable in nearly one in five cases, often due to obesity [22].…”

Section: Discussionmentioning

confidence: 99%

Transient elastography reliably estimates liver fibrosis in autoimmune hepatitis

Mahmud¹,

Doshi²,

Forde³

et al. 2019

ceh

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Aim of the studyAutoimmune hepatitis (AIH) may result in liver fibrosis and cirrhosis. While the gold standard for staging fibrosis is biopsy, transient elastography (TE) represents a non-invasive alternative. TE has been validated in several chronic liver diseases, but no data exist to establish an association between histologic fibrosis on biopsy and TE liver stiffness measurements among a United States cohort of AIH patients.Material and methodsWe conducted a retrospective cohort study of 53 AIH patients who received TE assessment and liver biopsy. Histologic fibrosis was classified as advanced (F3-F4) or mild/moderate (F0-F2). Liver stiffness by TE was measured in kilopascals (kPa). We performed a score test for trend to test the association between histologic fibrosis stage and increasing TE kPa categories. Analyses incorporated probe type (medium or extra-large) and body mass index (BMI). Linear regression was used to generate predicted associations between median kPa and histologic fibrosis score with the medium probe.ResultsThe cohort was primarily female (83%) with median age 56.3 years. Increasing kPa category was associated with worsening fibrosis stage when using the medium probe (p = 0.04), but not the extra-large probe (p = 0.40). BMI, however, differed between these groups (median 25.8 vs. 33.1, respectively, p < 0.001). In adjusted linear regression, increasing median kPa corresponded well to worsening fibrosis stage (p = 0.003).ConclusionsIn a United States AIH cohort, increasing TE kPa measurements are associated with worsening histologic fibrosis staging. While medium probe performance was superior to the extra-large probe, significant variation in BMI between groups may explain this difference.

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“…For similar reasons, 1 set of cutoff values was chosen according to the recommendations for the XL probe, which was used in the vast majority of patients. We have previously shown for obese patients that reliable prediction of advanced fibrosis appears to be possible even if formal criteria of successful measurements are not completely met [17].…”

Section: Te and Capmentioning

confidence: 99%

A 2-step fast-track elastometry service for advanced workup of nonalcoholic fatty liver disease (NAFLD) patients – single-center real-world experience of outpatient clinical practice

et al. 2019

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Introduction and aims Nonalcoholic fatty liver disease (NAFLD) is increasing globally with an estimated prevalence of approximately 25 %. Nonalcoholic steatohepatitis as the progressive disease entity often leads to fibrosis and end-stage disease. The magnitude of NAFLD patients are not diagnosed and have no access to further clinical assessment. Diagnostic pathways for individual risk evaluation fitting with available resources are of utmost importance in real-world clinical practice. Methods Retrospective analysis of 1346 anonymized outpatient datasets at Würzburg University Hospital, Germany. Transient elastography (TE) with controlled attenuation parameter and laboratory-based risk scores (NFS, FIB-4) were the main diagnostic workup tools for risk stratification. Results After preselection based on questionnaire information NAFLD still accounts for one-fifth of patients in the liver outpatient service. More than 80 % of NAFLD patients receive their first-time diagnosis in our unit. Laboratory-based risk scores and TE are valuable tools for second-step risk assessment as shown in our clinical data analysis. Moreover, 65 % of NAFLD patients use inpatient services for at least 1 day. The policy to perform liver biopsy in high-risk patients above the recommended threshold of 9.6 kPa if any clinical doubt exists regarding the diagnosis of cirrhosis leads to a histological down staging in almost 80 %. Conclusion Questionnaire-based referral from primary care followed by broadly available fast-track TE and eventually liver biopsy for selected patients is the standard practice in our unit. This approach represents a feasible model to handle the large gap between availability and clinical need for TE facilities.

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Feasibility of liver stiffness measurement in morbidly obese patients undergoing bariatric surgery using XL probe

Abstract: LSM with XL probe is feasible in almost two-thirds of morbidly obese patients with a BMI ≥50 kg/m(2). Reliable prediction of advanced fibrosis appears to be possible even if formal criteria of successful measurements are not met.

Cited by 21 publications

References 32 publications

A Pragmatic Approach Identifies a High Rate of Nonalcoholic Fatty Liver Disease With Advanced Fibrosis in Diabetes Clinics and At‐Risk Populations in Primary Care

A Pragmatic Approach Identifies a High Rate of Nonalcoholic Fatty Liver Disease With Advanced Fibrosis in Diabetes Clinics and At‐Risk Populations in Primary Care

Transient elastography reliably estimates liver fibrosis in autoimmune hepatitis

A 2-step fast-track elastometry service for advanced workup of nonalcoholic fatty liver disease (NAFLD) patients – single-center real-world experience of outpatient clinical practice

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