Transient elastography (FibroScan®) with controlled attenuation parameter in the assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease - Where do we stand?

Table 1 Limitations of transient elastography with controlled attenuation parameter

Limitations	Explanation
Ascites	Elastic waves do not travel through liquids
Obesity	BMI > 30 kg/m2 is associated with TE failure. With the development of the XL probe, the failure rate in obese patients has decreased
Acute hepatitis	Tissue changes in acute hepatitis may increase LSM
Chronic hepatitis with transaminases flare	At ALT levels greater than 5 × the upper normal limit, there is a risk of overestimating the fibrosis stage. LSM interpretations in patients with high ALT levels must be made with caution
Extrahepatic cholestasis	Increases LSM independently of fibrosis stage
Congestive heart failure	May lead to increased LSM because of an increased blood volume in the liver
Narrow intercostal spaces	Associated with a lower success rate or failed acquisition of LSM. Reduced failure rate with the development of the S probe

BMI: Body mass index; LSM: Liver stiffness measurement; ALT: Alanine-aminotransferase.

Table 2 Advantages of transient elastography with controlled attenuation parameter

Most widely used and validated non-invasive technique

High range of values

Well defined quality criteria

Good reproducibility

Detects liver stiffness and steatosis from the same region of interest

Excellent for the exclusion of cirrhosis

Prognostic value in cirrhosis

User-friendly

Short duration, painless

Applicable as a screening method in large populations

Table 3 Hazard ratio of hepatocellular carcinoma development in relation to liver stiffness measurement (according to Masuzaki et al[80] and Jung et al[81])

HCV		HBV
LSM (kPa)	HR	LSM (kPa)	HR
10.1-15	16.7	13.1-18	4.68
15.1-20	20.9	18.1-23	5.55
20.1-25	25.6	> 23	6.60
> 25	45.5

HCV: Hepatitis C virus infection; HBV: Hepatitis B virus infection; LSM: Liver stiffness measurement.

Table 4 Usefulness of liver stiffness measurement compared with liver biopsy in the detection of fibrosis in nonalcoholic fatty liver disease patients

Study	Probe	Cut-off (kPa)	Sensitivity	Specificity	Number of patients with liver biopsy
Fibrosis stage ≥ F2
Imajo et al[83] (2016)	M	11.0	61.7	100	142
Pathik et al[84] (2015)	M	9.1	Not reported	Not reported	110
Yoneda et al[87] (2007)	M	6.65	81.8	91.2	67
Cassinotto et al[88] (2015)	M	6.2	≥ 90	Not available	291
Wong et al[89] (2010)	M	7.0	88	74	246
Lupsor et al[90] (2010)	M	6.8	67	84	72
Yoneda et al[91] (2008)	M	6.65	88	74	97
Kumar et al[92] (2013)	M	7.0	78	79	205
Fibrosis stage ≥ F3
Imajo et al[83] (2016)	M	11.4	85.7	83.8	142
Pathik et al[84] (2015)	M	12.0	90	80	110
Yoneda et al[87] (2007)	M	8.0	87.5	84.3	67
Cassinotto et al[88] (2015)	M	8.2	≥ 90	Not available	291
Wong et al[89] (2010)	M	8.7	84	83	246
Lupsor et al[90] (2010)	M	10.4	100	97	72
Yoneda et al[91] (2008)	M	9.8	85	81	97
Kumar et al[92] (2013)	M	9.0	85	88	205
Fibrosis stage F4
Imajo et al[83] (2016)	M	14.0	100	75.9	142
Pathik et al[84] (2015)	M	20.0	90	80	110
Yoneda et al[87] (2007)	M	17.0	100	98.4	67
Cassinotto et al[88] (2015)	M	9.5	≥ 90	Not available	291
Wong et al[89] (2010)	M	10.3	92	97	246
Yoneda et al[91] (2008)	M	17.5	100	97	97
Kumar et al[92] (2013)	M	11.8	90	88	205

Table 5 Performance of controlled attenuation parameter compared with liver biopsy for the detection of various steatosis grades

Study	Etiology of CLD	Probe	Cut-off (dB/m)	AUC	Sensitivity (%)	Specificity (%)	Number of patients with liver biopsy
Steatosis grade ≥ 1
Sasso et al[98] (2010)	CLD, ALD, NAFLD	M	238	0.91	91	81	115
de Lédinghen et al[100] (2012)	NAFLD, HCV, ALD, other	M	266	0.84	69	85	112
Shen et al[102] (2014)	NAFLD, HBV	M	253	0.92	88	83	189
Kumar et al[101] (2015)	HBV, HCV, NAFLD	M	214	0.68	64	64	317
Myers et al[99] (2012)	Hepatitis, NAFLD, other	M	289	0.79	68	88	153
Chan et al[103] (2014)	NAFLD, control	M	263	0.97	91	94	101
Imajo et al[83] (2016)	NAFLD, control	M	236	0.88	82.3	91	127
Lupșor-Platon et al[105]	HCV, HBV, NAFLD, other CLD	M	260	0.81	64.8	82.3	201
Steatosis grade ≥ 2
Sasso et al[98] (2010)	CLD, ALD, NAFLD	M	259	0.95	89	86	115
de Lédinghen et al[100] (2012)	NAFLD, HCV, ALD, other	M	311	0.86	57	94	112
Shen et al[102] (2014)	NAFLD, HBV	M	285	0.92	93	83	189
Kumar et al[101] (2015)	HBV, HCV, NAFLD	M	255	0.79	77	80	317
Myers et al[99] (2012)	Hepatitis, NAFLD, other	M	288	0.76	85	62	153
Chan et al[103] (2014)	NAFLD, control	M	263	0.86	96	67	101
Imajo et al[83] (2016)	NAFLD, control	M	270	0.73	64.3	73.6	127
Lupșor-Platon et al[105]	HCV, HBV, NAFLD, other CLD	M	285	0.82	69.7	85.1	201
Steatosis grade 3
Sasso et al[98] (2010)	CLD, ALD, NAFLD	M	292	0.89	100	78	115
de Lédinghen et al[100] (2012)	NAFLD, HCV, ALD, other	M	318	0.93	87	91	112
Shen et al[102] (2014)	NAFLD, HBV	M	310	0.88	92	79	189
Kumar et al[101] (2015)	HBV, HCV, NAFLD	M	305	0.91	71	92	317
Myers et al[99] (2012)	Hepatitis, NAFLD, other	M	283	0.70	94	47	153
Chan et al[103] (2014)	NAFLD, control	M	281	0.75	100	53	101
Imajo et al[83] (2016)	NAFLD, control	M	302	0.70	64.3	73.6	127
Lupșor-Platon et al[105] (2015)	HCV, HBV, NAFLD, other CLD	M	294	0.83	83.3	82.5	201

CLD: Chronic liver disease; ALD: Alcoholic liver disease; NAFLD: Nonalcoholic fatty liver disease; HBV: Hepatitis B virus; HCV: Hepatitis C virus.