Liver, Pancreas and Biliary Tract
Performance and utility of transient elastography and noninvasive markers of liver fibrosis in primary biliary cirrhosis

https://doi.org/10.1016/j.dld.2011.06.011Get rights and content

Abstract

Background

The performance of transient elastography in primary biliary cirrhosis has yet to be fully established.

Aim

To assess: (1) the performance of transient elastography in identifying significant fibrosis in primary biliary cirrhosis by comparison with surrogate markers (AST platelet ratio index (APRI), FIB-4, Fibroindex, Forns, aspartate aminotransferase/alanine aminotransferase ratio); (2) the correlation between liver stiffness and Mayo score prognostic index.

Methods

One hundred and twenty patients with primary biliary cirrhosis were consecutively enrolled. The performance of each marker and of liver stiffness was compared with histological staging and METAVIR at time of liver biopsy.

Results

The area under receiver operating characteristic (ROC) of liver stiffness were 0.87, 0.88, 0.99 for histological stage ≥II, ≥III and =IV and 0.89, 0.92, 0.99 for METAVIR ≥2, ≥3 and =4. Transient elastography alone proved better able in identifying any grade of fibrosis or cirrhosis than noninvasive markers. Combining each surrogate marker with transient elastography did not improve the area under ROC. Transient elastography correlated positively with the Mayo score (P < 0.001). Logistic regression analysis showed that transient elastography was associated with an advanced fibrosis (P < 0.001).

Conclusions

Transient elastography proved a simple, reliable and useful method for assessing liver fibrosis in primary biliary cirrhosis, whereas noninvasive surrogate markers proved unsatisfactory in predicting significant fibrosis.

Introduction

How to assess the severity of liver fibrosis has become a hot topic in hepatological research in the last five years. There are several reasons for increasing interest in this issue, including the need for flexible prognostic markers for longitudinal follow-up, as well as for fast, reliable and convenient tools that are acceptable to patients. The recent literature on this issue has focused on several noninvasive markers (i.e. APRI, FIB-4, FORNS) and particularly on transient elastography (TE) for measuring liver fibrosis [1]. All these methods have been proposed as surrogate markers of liver fibrosis, and validated in study populations mainly comprising patients with chronic hepatitis C. The overall reliability of noninvasive serum markers enables significant liver fibrosis (or cirrhosis) to be detected, and patients to be allocated to three categories, i.e. cases with no or mild fibrosis, those with cirrhosis, and those with fibrosis of intermediate severity [1].

To improve the diagnostic accuracy of noninvasive serum markers and TE, it has been suggested that these methods should be validated in other patients with chronic liver disease, including alcoholic and non-alcoholic liver disease and chronic cholestasis [2].

Corpechot et al. assessed the diagnostic performance of TE in 73 patients with primary biliary cirrhosis (PBC) and in 28 patients with primary sclerosing cholangitis (PSC) [3]. Liver stiffness measurements were compared with liver biopsy staging and serum hyaluronic acid levels. The results obtained in these cholestatic patients were similar to those reported in previous studies on patients with hepatitis C, confirming the accuracy and simplicity of TE in the assessment of liver fibrosis [3].

In another study conducted in Spain 80 patients with PBC were studied using TE and the results were compared with liver biopsy findings [4]. The authors observed a significant correlation between TE measurements and liver biopsies.

A recent Japanese study compared the diagnostic performance of TE in chronic hepatitis C and non-viral chronic liver disease [5]. Though the authors did not analyse patients with PBC separately, they concluded that TE can be used as an alternative to liver biopsy for assessing liver fibrosis not only in patients with chronic hepatitis C, but also in those with non-viral chronic liver disease.

A recent study compared FibroScan, magnetic resonance imaging (MRI), magnetic resonance (MR)-spectroscopy and serum markers for the assessment of liver fibrosis and steatosis in 45 patients with PBC [6]. Contrast-enhanced MRI and FibroScan were equally effective in detecting fibrosis, whilst MR-spectroscopy proved the best method for detecting steatosis.

The aims of the current study were to assess: (1) the validity of TE in patients with PBC by comparison with a battery of surrogate markers of hepatic fibrosis in diagnosing significant fibrosis or cirrhosis; (2) the correlation between liver stiffness and Mayo score prognostic index.

Section snippets

Patients

One hundred and twenty patients with PBC were consecutively enrolled in this study between January and December 2009. PBC was defined according to the EASL 2009 guidelines [7]; 112 patients (93.3%) had anti-mitochondrial antibody positivity of at least 1:40, whilst 8 had an antinuclear antibody positivity of at least 1:160, fulfilling the criteria for a diagnosis of AMA-negative PBC. Each patient included in the study underwent a liver biopsy within 6 months of their liver stiffness measurement

Results

Six (5%) of 120 patients were excluded because their LS measurement was judged unreliable (due to an unsuccessful acquisition in 4 patients and a success rate below 60% in 2, all obese females with BMI > 34). We therefore analysed 114 patients whose clinical details are summarised in Table 1. There were 8 men and 96 women, with a mean age of 58 ± 12 years. There were 18 patients (16%) in histological stage I, 40 (35%) in stage II, 39 (34%) in stage III and 17 (15%) in stage IV.

Discussion

The results of our study indicate that TE is a simple and effective method for assessing liver fibrosis in PBC, whereas noninvasive surrogate markers proved unsatisfactory in predicting histological and fibrosis stage. TE also correlated significantly with the Mayo risk score, indicating that it is suitable for use as a prognostic method for liver disease.

As far as we know, this is the study on TE involving the largest number of PBC patients seen at a single centre. All our patients were

Financial disclosure

This work was partially supported by a University grant (ex 60% fund).

Conflict of interest statement

None declared.

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