Next Article in Journal
Metal Ion Release, Clinical and Radiological Outcomes in Large Diameter Metal-on-Metal Total Hip Arthroplasty at Long-Term Follow-Up
Next Article in Special Issue
Prediction of Nonalcoholic Fatty Liver Disease Using Noninvasive and Non-Imaging Procedures in Japanese Health Checkup Examinees
Previous Article in Journal
Hypo-Expression of Flice-Inhibitory Protein and Activation of the Caspase-8 Apoptotic Pathways in the Death-Inducing Signaling Complex Due to Ischemia Induced by the Compression of the Asphyxiogenic Tool on the Skin in Hanging Cases
Previous Article in Special Issue
Predictive Value of Serum Ferritin in Combination with Alanine Aminotransferase and Glucose Levels for Noninvasive Assessment of NAFLD: Fatty Liver in Obesity (FLiO) Study
Open AccessReview

Diagnostic Accuracy of FibroScan and Factors Affecting Measurements

1
Liver Center, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, Japan
2
Department of Laboratory Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, Japan
3
Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
4
Department of Clinical Laboratory Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
*
Author to whom correspondence should be addressed.
Diagnostics 2020, 10(11), 940; https://doi.org/10.3390/diagnostics10110940
Received: 8 September 2020 / Revised: 10 November 2020 / Accepted: 11 November 2020 / Published: 12 November 2020
(This article belongs to the Special Issue Fatty Liver Disease: Diagnostic, Predictive and Prognostic Markers)

Abstract

Evaluating liver steatosis and fibrosis is important for patients with non-alcoholic fatty liver disease. Although liver biopsy and pathological assessment is the gold standard for these conditions, this technique has several disadvantages. The evaluation of steatosis and fibrosis using ultrasound B-mode imaging is qualitative and subjective. The liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) determined using FibroScan are the evidence-based non-invasive measures of liver fibrosis and steatosis, respectively. The LSM and CAP measurements are carried out simultaneously, and the median values of more than ten valid measurements are used to quantify liver fibrosis and steatosis. Here, we demonstrate that the reliability of the LSM depends on the interquartile range to median ratio (IQR/Med), but CAP values do not depend on IQR/Med. In addition, the LSM is affected by inflammation, congestion, and cholestasis in addition to fibrosis, while CAP values are affected by the body mass index in addition to steatosis. We also show that the M probe provides higher LSM values but lower CAP values than the XL probe in the same population. However, there was no statistically significant difference between the diagnostic accuracies of the two probes. These findings are important to understand the reliability of FibroScan measurements and the factors influencing measurement values for all patients.
Keywords: non-alcoholic fatty liver disease; hepatic steatosis; hepatic inflammation; transient elastography; liver stiffness measurement; controlled attenuation parameter non-alcoholic fatty liver disease; hepatic steatosis; hepatic inflammation; transient elastography; liver stiffness measurement; controlled attenuation parameter

1. Introduction

Non-alcoholic fatty liver disease (NAFLD) is pathologically characterized by hepatic steatosis, lobular inflammation, hepatocyte ballooning, and liver fibrosis. According to the fatty liver inhibition of progression (FLIP) algorithm, NAFLD is diagnosed when the steatosis rate exceeds 5% [1]. Liver fibrosis is associated with the prognosis of patients with NAFLD [2,3]. Therefore, assessments of hepatic steatosis and liver fibrosis are important in the daily clinical management of NAFLD. Although liver biopsy and pathology is the gold standard for assessing steatosis and fibrosis, this technique is invasive and expensive and suffers from sampling error and diagnostic variation among observers [4,5,6]. The discordance of one fibrosis stage or more has been reported to be 41% in the evaluation of two tissues taken from different parts of the right lobe of the liver [5]. Kuwashiro et al. have recently shown that the interobserver concordance rates for NAS, steatosis, inflammation, ballooning, fibrosis, and NASH diagnosis were 26.7, 62.7, 51.3, 48.7, 43.3, and 50.7%, respectively [6]. Therefore, a non-invasive and objective method of assessing steatosis and fibrosis is important in NAFLD practice. The efficacy of various non-invasive biomarkers such as circulating biomarkers, scoring systems, and calculating formulas has been reported [7]. Steatosis and fibrosis can also be evaluated using ultrasound B-mode imaging, although the method is limited because it is subjective and semiquantitative [8,9,10]. Yajima et al. have shown that the combination of ultrasonographical findings of liver–kidney contrast, vascular blurring, and deep attenuation enables us to grade fatty change semi-quantitatively [8]. Magnetic resonance elastography (MRE) and ultrasound elastography have been reported as effective methods to compensate for these problems [11,12]. MRE has a higher area under the receiver operating characteristic curve (AUROC) value than one type of ultrasound elastography, FibroScan (Echosens, Paris, France) [12,13], but it is costly to implement. FibroScan is an evidence-based, transient elastography instrument for non-invasive evaluation of liver steatosis and fibrosis [14]. FibroScan can also be used to identify non-alcoholic steatohepatitis with significant activity and fibrosis when its results are combined with aspartate aminotransferase (AST) levels [15,16]. FibroScan is becoming an increasingly important modality in NAFLD practice, as it was recently used to identify patients eligible for NAFLD-related clinical trials.
Recently, a new disease concept called metabolic-associated fatty liver disease (MAFLD) was proposed [17], for which the Asian Pacific Association for the Study of the Liver described the diagnosis and management in its clinical practice guidelines [18]. Thus, fatty liver disease, which is included in chronic liver disease concepts such as NAFLD and MAFLD, is being addressed globally.
FibroScan provides two parameters—the liver stiffness measurement (LSM) and controlled attenuation parameter (CAP)—which are useful for assessing the degree of liver fibrosis and steatosis, respectively. It should be noted that CAP measurement requires special CAP software. FibroScan systems are equipped with two types of probe for adults: an M probe for use in most patients and an XL probe for obese patients. It is important to note that the probes have provided conflicting measurements of both LSM and CAP [19]. In this review, we summarize the diagnostic accuracy and reliability of the measurement values of the LSM and CAP and investigate the factors affecting these measurements. We further compare the M and XL probes for LSM and CAP measurements.

2. LSM

2.1. Diagnostic Accuracy of LSM in Patients with NAFLD

The LSM is a measure of the speed of the shear wave that is generated by a push pulse as it passes through the liver tissue. The shear wave propagates faster in hard liver tissue than in soft liver tissue. The LSM values range from 1.5 to 75.0 kPa based on this property. Several studies have demonstrated the utility of the LSM for assessing liver fibrosis in patients with various chronic liver diseases including NAFLD. The studies on NAFLD patients are summarized in Table 1 [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34]. The AUROCs for detecting fibrosis stages ≥1, ≥2, ≥3, and 4 have been reported as 0.78–0.97, 0.77–0.99, 0.73–1.00, and 0.89–0.997, respectively. Yoneda et al. were the first to report the usefulness of LSM using the M probe in patients with NAFLD [20]. To date, there is not enough evidence to support the usefulness of FibroScan with the XL probe compared with the M probe. Friedrich-Rust et al. reported that AUROCs for detecting fibrosis stages ≥2, ≥3, and 4 using the XL probe were 0.81, 0.84, and 0.95 based on a pilot study [25]. Oeda et al. directly compared the diagnostic accuracies with the M and XL probes and concluded that there was no difference between the AUROCs with the two probes (stage ≥2: 0.777 vs. 0.787, p = 0.710; stage ≥3: 0.836 vs. 0.806, p = 0.303; stage 4: 0.971 vs. 0.970, p = 0.955) [33]. These findings imply that the diagnostic accuracy of the XL probe is comparable to that of the M probe. Recently, a model equipped with an automated probe selection tool (APST) was developed. Eddowes et al. used this model and evaluated the diagnostic performance of the LSM measured using the selected probes; 33% of the subjects were examined using the M probe, and 67% of the patients were examined using the XL probe as indicated by the APST. The AUROCs for detecting fibrosis stages ≥2, ≥3, and 4 were 0.77, 0.80, and 0.89, respectively, suggesting that the diagnostic performance of the LSM obtained using the probes selected by APST is comparable to that reported in previous studies.

2.2. Relationship between Measurement Variability and Reliability of the LSM

In the FibroScan measurement protocol, the LSM is obtained based on at least ten valid measurements, and the median value is used to evaluate liver fibrosis. Measurement “failures” are defined as examinations in which ten valid LSMs are not obtained despite ten or more measurements. Studies have shown that, in patients with ten valid LSMs, the interquartile range to median ratio (IQR/Med) affects the reliability of the LSM results [35,36]. Generally, the IQR/Med cutoff value, above which the LSM reliability is low, is 0.3. In clinical practice, however, it is not uncommon for the IQR/Med to be higher than 0.3 if the median value is low; in these cases, the LSM is considered to be unreasonable. Therefore, it is important to evaluate reliability in terms of LSM values. Boursier et al. defined ranges for IQR/Med and Med to evaluate the reliability of examination: IQR/Med ≤ 0.1 with any Med value indicates very reliable measures; IQR/Med > 0.1 and ≤0.3 with any Med value or IQR/Med > 0.3 with Med < 7.1 kPa are considered to indicate reliable measures; and IQR/Med > 0.3 with Med ≥ 7.1 kPa is considered to indicate poor reliability [36]. The success rate of the acquisitions conducted to obtain ten valid measurements does not affect the diagnostic accuracy for liver fibrosis [35,36,37]. Therefore, the consensus is that the success rate does not represent reliability, so the success rate is not displayed on the operation screens of the current FibroScan models.

2.3. Factors Affecting the LSM

Several factors affect the LSM in chronic liver disease. We included NAFLD data in this group because few studies on LSM have been conducted exclusively on patients with NAFLD. The LSM is increased by inflammation, venous pressure, cholestasis, and amyloid deposition in the liver [38,39,40,41,42,43,44]. Mueller et al. reported that an increase in bilirubin by 1 mg/dL causes an increase in the LSM by around 1 kPa, an increase in the hepatic venous pressure by 2 cm causes an increase in the LSM by around 1 kPa, and an increase in the AST by 100 U/l causes an increase in the LSM of around 4 kPa [45]. Further, the impact of the AST on the LSM is higher in patients with alcoholic liver disease than in those with hepatitis C [46]. Once these influencing factors are attenuated, the LSM decreases accordingly. Abstaining from alcohol consumption has also been shown to decrease the LSM in patients with alcoholic liver disease [47]. Administering diuretics to patients with high venous pressure also decreases the LSM [41]. Animal experiments indicated that reversing the ligation of the bile duct immediately lowers an elevated LSM [42].
It is recommended that FibroScan be performed after overnight fasting, or at least a few hours after a meal, because food intake also leads to increased LSM values [48,49,50]. Arena et al. measured the LSM after overnight fasting and after standardized liquid meal intake; based on the results, it was suggested that fasting for 120 minutes is required before examination [50]. Mederacke et al. showed that the postprandial LSM is elevated following the intake of a standardized continental breakfast and normalizes to the fasting level 210 min after starting the meal [48].

3. CAP

3.1. Diagnostic Accuracy of the CAP in Patients with NAFLD

The CAP is a measure of the attenuation of the ultrasound beam. The stronger the liver steatosis is, the more the ultrasound beam passing through the liver tissue is attenuated. CAP values range from 100 to 400 dB/m based on this property [51]. Like the LSM, the CAP is effective for diagnosing liver steatosis in patients with various chronic liver diseases [52]. The studies on patients with NAFLD are summarized in Table 2 [19,31,32,33,34,53,54]. The AUROCs for detecting steatosis scores of ≥1, ≥2, and 3 have been reported as 0.77–0.97, 0.638–0.92, and 0.67–0.83, respectively. Caussy et al. reported that the AUROC was 0.80 for the diagnosis of steatosis of ≥5% and 0.87 for the diagnosis of steatosis ≥ 10% based on the proton density fat fraction measured by magnetic resonance imaging (MRI-PDFF) as a reference standard [55].

3.2. Relationship between Measurement Variability and Reliability for the CAP

CAP and LSM measurements are carried out simultaneously, and the median values of ten valid measurements are used to quantify liver steatosis. On the operation screen of the FibroScan, the IQR is displayed, but the IQR/Med is not because it is generally thought that the latter does not affect the measurement reliability [56,57]. Myers et al. showed that, in the detection of steatosis ≥ 10%, there were no significant differences between the AUROCs when IQR/Med ≥ 15% and <15% (p = 0.29) and when IQR/Med ≥ 11% and <11% (p = 0.63) [56]. Jung et al. showed that the IQR/Med is not an independent predictor of discordance between liver biopsy and CAP value by using multivariate logistic regression analyses [57]. However, there is evidence that the IQR is associated with reliability.
Wong et al. stratified IQR values into three groups (<20, 21–39, and ≥40 dB/m) and determined the AUROCs of these groups (0.86, 0.89, and 0.76, respectively). There was a significant difference between the CAP values in the groups with IQRs of <40 and ≥40 dB/m (0.90 vs. 0.77, respectively, p = 0.004) [58], suggesting that variation in the CAP affects the diagnostic accuracy.

3.3. Factors Affecting the CAP

As with the LSM, we summarized the factors affecting the CAP in chronic liver disease and included NAFLD data as well. The measured CAP values can be affected by various factors in addition to liver steatosis. Studies that examined influencing factors using multivariate analyses are shown in Table 3 [53,56,57,59,60,61,62,63]. The data were adjusted for liver steatosis in all of the studies. Body mass index (BMI) was reported to be independently associated with CAP in six studies. Triglyceride was reported to affect the CAP in one study and not affect it in four studies. Hence, it was concluded that triglyceride does not affect the CAP. Age, sex, liver fibrosis, total cholesterol, and fasting glucose level were not found to be factors that affected the CAP.
Table 4 shows whether factors affecting the LSM or the CAP also affect the CAP or the LSM, respectively. Inflammation and liver function, which affected the LSM, were reported not to affect the CAP [53,56,57,59,60,61,62,63]. There was insufficient evidence that venous pressure, cholestasis, amyloidosis, or food intake affected the CAP. One report found that food intake decreased the CAP, and another found that it had no effect on it [64,65]. Liver steatosis and BMI, which affected the CAP, were reported not to affect the LSM after adjusting for the stage of fibrosis [23].

4. Probe Comparison and Selection

FibroScan is equipped with two types of probes for adults: an M probe for use on the majority of patients and an XL probe designed for obese patients. In addition, an S probe is generally used on pediatric patients. The XL probe can take measurements at greater depths (35–75 mm) than the M probe (25–65 mm) [25]. The diameter of the transducer of the XL probe is larger (10 mm) than that of the M probe (7 mm). The center frequency of the ultrasound waves is 2.5 MHz for the XL probe and 3.5 MHz for the M probe. In addition, it is recommended to use the M probe on any patient with a skin-capsular distance (SCD) of ≤25 mm and the XL probe on any patient with an SCD of >25 mm. However, as the automated probe selection tool (APST) is embedded in the software of the late FibroScan 502 model and later models, the measurement of SCD using ultrasound B-mode imaging is not required when using these models.
Both the LSM and CAP are designed to have identical values from the M and XL probes. The shear wave frequency of the LSM is 50 Hz for both probes. Although the center frequency differs between the M probe (3.5 MHz) and the XL probe (2.5 MHz), the CAP values captured using the XL probe are adjusted to 3.5 MHz [66]. Therefore, the ultrasound attenuation with the probes should be the same in the same region in the same patient, while the resulting CAP values could differ because the probes have different regions of interest.
Generally, the LSM obtained using the M probe is higher than that obtained using the XL probe in the same population [19,28,33,67,68,69]. One study showed that LSMs measured using the XL probe were 1.7 ± 2.3 kPa lower than those measured by the M probe by pairwise examination [28]. Another study reported that the mean difference between the LSM measurements was 2.3 kPa (the median difference was 1.4 kPa) [67]. A third study reported that the median difference between the XL and M probe LSM measurements was 2.6 kPa [68]. Wong et al. estimated the LSM values that would be captured with the M probe from results obtained with the XL probe (LSM-XL) by using linear regression analysis, yielding the following equations: 1.110 × LSM-XL + 0.954 for patients with BMIs 25.0–30.0 kg/m2 and 1.204 × LSM-XL + 0.931 for patients with BMIs > 30.0 kg/m2 [68]. Previous studies showed that the XL probe returns higher CAP values than the M probe [19,33,70]. However, regardless of the probe used, the cutoff values, sensitivities, specificities, positive predictive values, and negative predictive values were comparable for the diagnosis of steatosis grades ≥ S1, ≥ 2, and 3 [71]. Unlike LSM, there is insufficient evidence comparing the XL probe with the M probe for CAP measurements, and it remains unclear how much the higher CAP values obtained by XL probe are compared with those obtained by the M probe. Oeda et al. recently reported probe-specific cutoff values for the CAP and LSM and showed that there was no significant difference between the AUROCs with the two probes using these cutoff values [33].

5. Conclusions

In patients with NAFLD, it is important to evaluate fibrosis and steatosis because fibrosis is associated with clinical prognosis, and steatosis is a criterion for NAFLD diagnosis. Various types of tests are available for the surveillance of NAFLD patients [72]. Among them, the LSM and CAP obtained by FibroScan are useful and cost-effective measures for the diagnosis of liver fibrosis and steatosis. However, users should bear in mind the factors that can influence measurements besides fibrosis and steatosis: the LSM is affected by inflammation, venous pressure, cholestasis, amyloid deposition, and food intake, and the CAP is affected by the BMI. Moreover, it is necessary to evaluate the reliability of the obtained LSM values based on the IQR/Med, but the IQR/Med is not associated with the reliability of CAP values. In addition, it is important for FibroScan users to understand the reliability of measurement values and factors influencing the measurement values. Especially in cases when there is a discrepancy between the FibroScan results and clinical data, such as liver biopsy, biomarker measures, and observations with other imaging modalities, FibroScan results should be interpreted carefully as a possible indicator of liver fibrosis and steatosis in clinical application. In the future, it would be desirable to study the LSM and the CAP values corrected for factors affecting their measurement values.

Author Contributions

Conceptualization, S.O.; methodology, S.O.; investigation, S.O.; writing—original draft preparation, S.O.; writing—review and editing; E.S. and H.T.; visualization, K.T., A.O. and Y.M.; supervision, H.T.; project administration, S.O. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Acknowledgments

We thank Stephanie Knowlton, PhD, from Edanz Group (https://en-author-services.edanzgroup.com/ac) for editing a draft of this manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Bedossa, P.; Poitou, C.; Veyrie, N.; Bouillot, J.-L.; Basdevant, A.; Paradis, V.; Tordjman, J.; Clement, K. Histopathological algorithm and scoring system for evaluation of liver lesions in morbidly obese patients. Hepatology 2012, 56, 1751–1759. [Google Scholar] [CrossRef]
  2. Angulo, P.; Kleiner, D.E.; Dam-Larsen, S.; Adams, L.A.; Björnsson, E.S.; Charatcharoenwitthaya, P.; Mills, P.R.; Keach, J.C.; Lafferty, H.D.; Stahler, A.; et al. Liver Fibrosis, but No Other Histologic Features, Is Associated with Long-term Outcomes of Patients with Nonalcoholic Fatty Liver Disease. Gastroenterology 2015, 149, 389–397.e10. [Google Scholar] [CrossRef]
  3. Dulai, P.S.; Singh, S.; Patel, J.; Soni, M.; Prokop, L.J.; Younossi, Z.; Sebastiani, G.; Ekstedt, M.; Hagstrom, H.; Nasr, P.; et al. Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: Systematic review and meta-analysis. Hepatology 2017, 65, 1557–1565. [Google Scholar] [CrossRef]
  4. Piccinino, F.; Sagnelli, E.; Pasquale, G.; Giusti, G.; Battocchia, A.; Bernardi, M.; Bertolazzi, R.; Bianchi, F.; Brunelli, E.; Budillon, G.; et al. Complications following percutaneous liver biopsy. J. Hepatol. 1986, 2, 165–173. [Google Scholar] [CrossRef]
  5. Ratziu, V.; Charlotte, F.; Heurtier, A.; Gombert, S.; Giral, P.; Bruckert, E.; Grimaldi, A.; Capron, F.; Poynard, T. Sampling Variability of Liver Biopsy in Nonalcoholic Fatty Liver Disease. Gastroenterology 2005, 128, 1898–1906. [Google Scholar] [CrossRef]
  6. Kuwashiro, T.; Takahashi, H.; Hyogo, H.; Ogawa, Y.; Imajo, K.; Yoneda, M.; Nakahara, T.; Oeda, S.; Tanaka, K.; Amano, Y.; et al. Discordant pathological diagnosis of non-alcoholic fatty liver disease: A prospective multicenter study. JGH Open 2019, 4, 497–502. [Google Scholar] [CrossRef] [PubMed]
  7. Tincopa, M.A. Diagnostic and interventional circulating biomarkers in nonalcoholic steatohepatitis. Endocrinol. Diabetes Metab. 2020, 3, 00177. [Google Scholar] [CrossRef] [PubMed]
  8. Yajima, Y.; Ohta, K.; Narui, T.; Abe, R.; Suzuki, H.; Ohtsuki, M. Ultrasonographical Diagnosis of Fatty Liver: Significance of the Liver-Kidney Contrast. Tohoku J. Exp. Med. 1983, 139, 43–50. [Google Scholar] [CrossRef] [PubMed]
  9. Marshall, R.H.; Eissa, M.; Bluth, E.; Gulotta, P.M.; Davis, N.K. Hepatorenal Index as an Accurate, Simple, and Effective Tool in Screening for Steatosis. Am. J. Roentgenol. 2012, 199, 997–1002. [Google Scholar] [CrossRef] [PubMed]
  10. Shen, L. Correlation between ultrasonographic and pathologic diagnosis of liver fibrosis due to chronic virus hepatitis. World J. Gastroenterol. 2006, 12, 1292–1295. [Google Scholar] [CrossRef]
  11. Yoneda, M.; Honda, Y.; Nogami, A.; Imajo, K.; Nakajima, A. Advances in ultrasound elastography for nonalcoholic fatty liver disease. J. Med Ultrason. 2020, 1–13. [Google Scholar] [CrossRef]
  12. Honda, Y.; Yoneda, M.; Imajo, K.; Nakajima, A. Elastography Techniques for the Assessment of Liver Fibrosis in Non-Alcoholic Fatty Liver Disease. Int. J. Mol. Sci. 2020, 21, 4039. [Google Scholar] [CrossRef] [PubMed]
  13. Hsu, C.; Caussy, C.; Imajo, K.; Chen, J.; Singh, S.; Kaulback, K.; Le, M.-D.; Hooker, J.; Tu, X.; Bettencourt, R.; et al. Magnetic Resonance vs Transient Elastography Analysis of Patients with Nonalcoholic Fatty Liver Disease: A Systematic Review and Pooled Analysis of Individual Participants. Clin. Gastroenterol. Hepatol. 2019, 17, 630–637.e8. [Google Scholar] [CrossRef] [PubMed]
  14. Zhang, X.; Wong, G.L.-H.; Wong, V.W.-S. Application of transient elastography in nonalcoholic fatty liver disease. Clin. Mol. Hepatol. 2019, 26, 128–141. [Google Scholar] [CrossRef] [PubMed]
  15. Newsome, P.N.; Sasso, M.; Deeks, J.J.; Paredes, A.; Boursier, J.; Chan, W.-K.; Yilmaz, Y.; Czernichow, S.; Zheng, M.-H.; Wong, V.W.-S.; et al. FibroScan-AST (FAST) score for the non-invasive identification of patients with non-alcoholic steatohepatitis with significant activity and fibrosis: A prospective derivation and global validation study. Lancet Gastroenterol. Hepatol. 2020, 5, 362–373. [Google Scholar] [CrossRef]
  16. Oeda, S.; Takahashi, H.; Imajo, K.; Seko, Y.; Kobayashi, T.; Ogawa, Y.; Moriguchi, M.; Yoneda, M.; Anzai, K.; Irie, H.; et al. Diagnostic accuracy of FibroScan-AST score to identify non-alcoholic steatohepatitis with significant activity and fibrosis in Japanese patients with non-alcoholic fatty liver disease: Comparison between M and XL probes. Hepatol. Res. 2020, 50, 831–839. [Google Scholar] [CrossRef]
  17. Eslam, M.; Sanyal, A.J.; George, J.; Neuschwander-Tetri, B.; Tiribelli, C.; Kleiner, D.E.; Brunt, E.; Bugianesi, E.; Yki-Järvinen, H.; Grønbæk, H.; et al. MAFLD: A Consensus-Driven Proposed Nomenclature for Metabolic Associated Fatty Liver Disease. Gastroenterology 2020, 158, 1999–2014.e1. [Google Scholar] [CrossRef]
  18. Eslam, M.; Sarin, S.K.; Wong, V.W.-S.; Fan, J.-G.; Kawaguchi, T.; Ahn, S.H.; Zheng, M.-H.; Shiha, G.; Yilmaz, Y.; Gani, R.; et al. The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease. Hepatol. Int. 2020. [Google Scholar] [CrossRef]
  19. Chan, W.-K.; Mustapha, N.R.N.; Wong, G.L.-H.; Wong, V.W.-S.; Mahadeva, S. Controlled attenuation parameter using the FibroScan® XL probe for quantification of hepatic steatosis for non-alcoholic fatty liver disease in an Asian population. United Eur. Gastroenterol. J. 2016, 5, 76–85. [Google Scholar] [CrossRef]
  20. Yoneda, M.; Fujita, K.; Inamori, M.; Nakajima, A.; Tamano, M.; Hiraishi, H. Transient elastography in patients with non-alcoholic fatty liver disease (NAFLD). Gut 2007, 56, 1330–1331. [Google Scholar] [CrossRef]
  21. Yoneda, M.; Mawatari, H.; Fujita, K.; Endo, H.; Iida, H.; Nozaki, Y.; Yonemitsu, K.; Higurashi, T.; Takahashi, H.; Kobayashi, N.; et al. Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with nonalcoholic fatty liver disease (NAFLD). Dig. Liver Dis. 2008, 40, 371–378. [Google Scholar] [CrossRef] [PubMed]
  22. Nobili, V.; Vizzutti, F.; Arena, U.; Abraldes, J.G.; Marra, F.; Pietrobattista, A.; Fruhwirth, R.; Marcellini, M.; Pinzani, M. Accuracy and reproducibility of transient elastography for the diagnosis of fibrosis in pediatric nonalcoholic steatohepatitis. Hepatology 2008, 48, 442–448. [Google Scholar] [CrossRef] [PubMed]
  23. Wong, V.W.-S.; Vergniol, J.; Wong, G.L.-H.; Foucher, J.; Chan, H.L.-Y.; Le Bail, B.; Choi, P.C.-L.; Kowo, M.; Chan, A.W.-H.; Merrouche, W.; et al. Diagnosis of fibrosis and cirrhosis using liver stiffness measurement in nonalcoholic fatty liver disease. Hepatology 2010, 51, 454–462. [Google Scholar] [CrossRef] [PubMed]
  24. Lupsor-Platon, M.; Badea, R.; Stefănescu, H.; Grigorescu, M.; Serban, A.; Radu, C.; Crişan, D.; Sparchez, Z.; Iancu, S.; Maniu, A. Performance of unidimensional transient elastography in staging non-alcoholic steatohepatitis. J. Gastrointest. Liver Dis. 2010, 19, 53–60. [Google Scholar]
  25. Friedrich-Rust, M.; Hadji-Hosseini, H.; Kriener, S.; Herrmann, E.; Sircar, I.; Kau, A.; Zeuzem, S.; Bojunga, J. Transient elastography with a new probe for obese patients for non-invasive staging of non-alcoholic steatohepatitis. Eur. Radiol. 2010, 20, 2390–2396. [Google Scholar] [CrossRef] [PubMed]
  26. Petta, S.; Di Marco, V.; Cammà, C.; Butera, G.; Cabibi, D.; Craxi, A. Reliability of liver stiffness measurement in non-alcoholic fatty liver disease: The effects of body mass index. Aliment. Pharmacol. Ther. 2011, 33, 1350–1360. [Google Scholar] [CrossRef] [PubMed]
  27. Friedrich-Rust, M.; Romen, D.; Vermehren, J.; Kriener, S.; Sadet, D.; Herrmann, E.; Zeuzem, S.; Bojunga, J. Acoustic radiation force impulse-imaging and transient elastography for non-invasive assessment of liver fibrosis and steatosis in NAFLD. Eur. J. Radiol. 2012, 81, e325–e331. [Google Scholar] [CrossRef]
  28. Wong, V.W.-S.; Vergniol, J.; Wong, G.L.-H.; Foucher, J.; Chan, A.W.-H.; Chermak, F.; Choi, P.C.-L.; Merrouche, W.; Chu, S.H.-T.; Pesque, S.; et al. Liver Stiffness Measurement Using XL Probe in Patients with Nonalcoholic Fatty Liver Disease. Am. J. Gastroenterol. 2012, 107, 1862–1871. [Google Scholar] [CrossRef]
  29. Kumar, R.; Rastogi, A.; Sharma, M.K.; Bhatia, V.; Tyagi, P.; Sharma, P.; Garg, H.; Kumar, K.N.C.; Bihari, C.; Sarin, S.K. Liver Stiffness Measurements in Patients with Different Stages of Nonalcoholic Fatty Liver Disease: Diagnostic Performance and Clinicopathological Correlation. Dig. Dis. Sci. 2013, 58, 265–274. [Google Scholar] [CrossRef]
  30. Pathik, P.; Ravindra, S.; Ajay, C.; Prasad, B.; Jatin, P.; Prabha, S. Fibroscan versus simple noninvasive screening tools in predicting fibrosis in high-risk nonalcoholic fatty liver disease patients from Western India. Ann. Gastroenterol. 2015, 28, 281–286. [Google Scholar]
  31. Imajo, K.; Kessoku, T.; Honda, Y.; Tomeno, W.; Ogawa, Y.; Mawatari, H.; Fujita, K.; Yoneda, M.; Taguri, M.; Hyogo, H.; et al. Magnetic Resonance Imaging More Accurately Classifies Steatosis and Fibrosis in Patients with Nonalcoholic Fatty Liver Disease Than Transient Elastography. Gastroenterology 2016, 150, 626–637.e7. [Google Scholar] [CrossRef] [PubMed]
  32. Eddowes, P.J.; Sasso, M.; Allison, M.; Tsochatzis, E.; Anstee, Q.M.; Sheridan, D.; Guha, I.N.; Cobbold, J.F.; Deeks, J.J.; Paradis, V.; et al. Accuracy of FibroScan Controlled Attenuation Parameter and Liver Stiffness Measurement in Assessing Steatosis and Fibrosis in Patients with Nonalcoholic Fatty Liver Disease. Gastroenterology 2019, 156, 1717–3170. [Google Scholar] [CrossRef] [PubMed]
  33. Oeda, S.; Takahashi, H.; Imajo, K.; Seko, Y.; Ogawa, Y.; Moriguchi, M.; Yoneda, M.; Anzai, K.; Aishima, S.; Kage, M.; et al. Accuracy of liver stiffness measurement and controlled attenuation parameter using FibroScan® M/XL probes to diagnose liver fibrosis and steatosis in patients with nonalcoholic fatty liver disease: A multicenter prospective study. J. Gastroenterol. 2019, 55, 428–440. [Google Scholar] [CrossRef] [PubMed]
  34. Cardoso, A.C.; Cravo, C.; Calçado, F.L.; Rezende, G.; Campos, C.F.F.; Neto, J.M.A.; Luz, R.P.; Soares, J.A.S.; Moraes-Coelho, H.S.; Leite, N.C.; et al. The performance of M and XL probes of FibroScan for the diagnosis of steatosis and fibrosis on a Brazilian nonalcoholic fatty liver disease cohort. Eur. J. Gastroenterol. Hepatol. 2020, 32, 231–238. [Google Scholar] [CrossRef] [PubMed]
  35. Lucidarme, D.; Foucher, J.; Le Bail, B.; Vergniol, J.; Castera, L.; Duburque, C.; Forzy, G.; Filoche, B.; Couzigou, P.; De Lédinghen, V. Factors of accuracy of transient elastography (fibroscan) for the diagnosis of liver fibrosis in chronic hepatitis C. Hepatology 2008, 49, 1083–1089. [Google Scholar] [CrossRef] [PubMed]
  36. Boursier, J.; Zarski, J.-P.; De Ledinghen, V.; Rousselet, M.-C.; Sturm, N.; LeBail, B.; Fouchard-Hubert, I.; Gallois, Y.; Oberti, F.; Bertrais, S.; et al. Determination of reliability criteria for liver stiffness evaluation by transient elastography. Hepatology 2013, 57, 1182–1191. [Google Scholar] [CrossRef]
  37. Kettaneh, A.; Marcellin, P.; Douvin, C.; Poupon, R.; Ziol, M.; Beaugrand, M.; De Lédinghen, V. Features associated with success rate and performance of fibroscan measurements for the diagnosis of cirrhosis in HCV patients: A prospective study of 935 patients. J. Hepatol. 2007, 46, 628–634. [Google Scholar] [CrossRef]
  38. Coco, B.; Oliveri, F.; Maina, A.M.; Ciccorossi, P.; Sacco, R.; Colombatto, P.; Bonino, F.; Brunetto, M.R. Transient elastography: A new surrogate marker of liver fibrosis influenced by major changes of transaminases. J. Viral Hepat. 2007, 14, 360–369. [Google Scholar] [CrossRef]
  39. Arena, U.; Vizzutti, F.; Corti, G.; Ambu, S.; Stasi, C.; Bresci, S.; Moscarella, S.; Boddi, V.; Petrarca, A.; Laffi, G.; et al. Acute viral hepatitis increases liver stiffness values measured by transient elastography. Hepatology 2007, 47, 380–384. [Google Scholar] [CrossRef]
  40. Sagir, A.; Erhardt, A.; Schmitt, M.; Häussinger, D. Transient elastography is unreliable for detection of cirrhosis in patients with acute liver damage. Hepatology 2007, 47, 592–595. [Google Scholar] [CrossRef]
  41. Millonig, G.; Friedrich, S.; Adolf, S.; Fonouni, H.; Golriz, M.; Mehrabi, A.; Stiefel, P.; Pöschl, G.; Büchler, M.W.; Seitz, H.K.; et al. Liver stiffness is directly influenced by central venous pressure. J. Hepatol. 2010, 52, 206–210. [Google Scholar] [CrossRef] [PubMed]
  42. Mueller, S.; Millonig, G.; Friedrich, S.; Welker, A.; Becker, P.; Reimann, F.; Seitz, H.K. 17 Extrahepatic Cholestasis Increases Liver Stiffness (Fibroscan ®) Irrespective of Fibrosis. Gastroenterology 2008, 134, 1718–1723. [Google Scholar] [CrossRef]
  43. Loustaud-Ratti, V.; Cypierre, A.; Rousseau, A.; Yagoubi, F.; Abraham, J.; Fauchais, A.-L.; Carrier, P.; Lefebvre, A.; Bordessoule, D.; Vidal, E.; et al. Non-invasive detection of hepatic amyloidosis: FibroScan, a new tool. Amyloid 2011, 18, 19–24. [Google Scholar] [CrossRef] [PubMed]
  44. Lanzi, A.; Gianstefani, A.; Mirarchi, M.G.; Pini, P.; Conti, F.; Bolondi, L. Liver AL amyloidosis as a possible cause of high liver stiffness values. Eur. J. Gastroenterol. Hepatol. 2010, 22, 895–897. [Google Scholar] [CrossRef] [PubMed]
  45. Mueller, S. Liver stiffness: A novel parameter for the diagnosis of liver disease. Hepatic Med. Evid. Res. 2010, 2, 49–67. [Google Scholar] [CrossRef]
  46. Mueller, S.; Englert, S.; Seitz, H.K.; Badea, R.; Erhardt, A.; Bozaari, B.; Beaugrand, M.; Lupsor-Platon, M. Inflammation-adapted liver stiffness values for improved fibrosis staging in patients with hepatitis C virus and alcoholic liver disease. Liver Int. 2015, 35, 2514–2521. [Google Scholar] [CrossRef]
  47. Mueller, S.; Millonig, G.; Sarovska, L.; Friedrich, S.; Reimann, F.M.; Pritsch, M.; Eisele, S.; Stickel, F.; Longerich, T.; Schirmacher, P.; et al. Increased liver stiffness in alcoholic liver disease: Differentiating fibrosis from steatohepatitis. World J. Gastroenterol. 2010, 16, 966–972. [Google Scholar] [CrossRef]
  48. Mederacke, I.; Wursthorn, K.; Kirschner, J.; Rifai, K.; Manns, M.P.; Wedemeyer, H.; Bahr, M.J. Food intake increases liver stiffness in patients with chronic or resolved hepatitis C virus infection. Liver Int. 2009, 29, 1500–1506. [Google Scholar] [CrossRef]
  49. Berzigotti, A.; De Gottardi, A.; Vukotic, R.; Siramolpiwat, S.; Abraldes, J.G.; García-Pagan, J.C.; Bosch, J. Effect of Meal Ingestion on Liver Stiffness in Patients with Cirrhosis and Portal Hypertension. PLoS ONE 2013, 8, e58742. [Google Scholar] [CrossRef]
  50. Arena, U.; Platon, M.L.; Stasi, C.; Moscarella, S.; Assarat, A.; Bedogni, G.; Piazzolla, V.; Badea, R.; Laffi, G.; Marra, F.; et al. Liver stiffness is influenced by a standardized meal in patients with chronic hepatitis C virus at different stages of fibrotic evolution. Hepatology 2013, 58, 65–72. [Google Scholar] [CrossRef]
  51. Sasso, M.; Beaugrand, M.; De Ledinghen, V.; Douvin, C.; Marcellin, P.; Poupon, R.; Sandrin, L.; Miette, V. Controlled Attenuation Parameter (CAP): A Novel VCTE™ Guided Ultrasonic Attenuation Measurement for the Evaluation of Hepatic Steatosis: Preliminary Study and Validation in a Cohort of Patients with Chronic Liver Disease from Various Causes. Ultrasound Med. Biol. 2010, 36, 1825–1835. [Google Scholar] [CrossRef] [PubMed]
  52. Shi, K.-Q.; Tang, J.-Z.; Zhu, X.-L.; Ying, L.; Li, D.-W.; Gao, J.; Fang, Y.-X.; Li, G.-L.; Song, Y.-J.; Deng, Z.-J.; et al. Controlled attenuation parameter for the detection of steatosis severity in chronic liver disease: A meta-analysis of diagnostic accuracy. J. Gastroenterol. Hepatol. 2014, 29, 1149–1158. [Google Scholar] [CrossRef] [PubMed]
  53. Chan, W.-K.; Mustapha, N.R.N.; Mahadeva, S. Controlled attenuation parameter for the detection and quantification of hepatic steatosis in nonalcoholic fatty liver disease. J. Gastroenterol. Hepatol. 2014, 29, 1470–1476. [Google Scholar] [CrossRef] [PubMed]
  54. Darweesh, S.K.; Omar, H.; Medhat, E.; Aziz, R.A.A.-A.; Ayman, H.; Saad, Y.; Yosry, A. The clinical usefulness of elastography in the evaluation of nonalcoholic fatty liver disease patients. Eur. J. Gastroenterol. Hepatol. 2019, 31, 1010–1016. [Google Scholar] [CrossRef] [PubMed]
  55. Caussy, C.; Alquiraish, M.H.; Nguyen, P.; Hernandez, C.; Cepin, S.; Fortney, L.E.; Ajmera, V.; Bettencourt, R.; Collier, S.; Hooker, J.; et al. Optimal threshold of controlled attenuation parameter with MRI-PDFF as the gold standard for the detection of hepatic steatosis. Hepatology 2018, 67, 1348–1359. [Google Scholar] [CrossRef]
  56. Myers, R.P.; Pollett, A.; Kirsch, R.; Pomier-Layrargues, G.; Beaton, M.; Levstik, M.; Duarte-Rojo, A.; Wong, D.; Crotty, P.; Elkashab, M. Controlled Attenuation Parameter (CAP): A noninvasive method for the detection of hepatic steatosis based on transient elastography. Liver Int. 2012, 32, 902–910. [Google Scholar] [CrossRef]
  57. Jung, K.S.; Kim, B.K.; Kim, S.U.; Chon, Y.E.; Cheon, K.H.; Kim, S.B.; Lee, S.H.; Ahn, S.S.; Park, J.Y.; Kim, D.Y.; et al. Factors Affecting the Accuracy of Controlled Attenuation Parameter (CAP) in Assessing Hepatic Steatosis in Patients with Chronic Liver Disease. PLoS ONE 2014, 9, e98689. [Google Scholar] [CrossRef]
  58. Wong, V.W.-S.; Petta, S.; Hiriart, J.-B.; Cammà, C.; Wong, G.L.H.; Marra, F.; Vergniol, J.; Chan, A.W.H.; Tuttolomondo, A.; Merrouche, W.; et al. Validity criteria for the diagnosis of fatty liver by M probe-based controlled attenuation parameter. J. Hepatol. 2017, 67, 577–584. [Google Scholar] [CrossRef]
  59. Sasso, M.; Tengher-Barna, I.; Ziol, M.; Miette, V.; Fournier, C.; Sandrin, L.; Poupon, R.; Cardoso, A.-C.; Marcellin, P.; Douvin, C.; et al. Novel controlled attenuation parameter for noninvasive assessment of steatosis using Fibroscan (®): Validation in chronic hepatitis C. J Viral Hepat. 2012, 19, 244–253. [Google Scholar]
  60. Kumar, M.; Rastogi, A.; Singh, T.; Behari, C.; Gupta, E.; Garg, H.; Kumar, M.; Bhatia, V.; Sarin, S.K. Controlled attenuation parameter for non-invasive assessment of hepatic steatosis: Does etiology affect performance? J. Gastroenterol. Hepatol. 2013, 28, 1194–1201. [Google Scholar] [CrossRef]
  61. Chon, Y.E.; Jung, K.S.; Kim, S.U.; Park, J.Y.; Park, Y.N.; Kim, D.Y.; Ahn, S.H.; Chon, C.Y.; Lee, H.W.; Park, Y.; et al. Controlled attenuation parameter (CAP) for detection of hepatic steatosis in patients with chronic liver diseases: A prospective study of a native Korean population. Liver Int. 2013, 34, 102–109. [Google Scholar] [CrossRef] [PubMed]
  62. Shen, F. Controlled attenuation parameter for non-invasive assessment of hepatic steatosis in Chinese patients. World J. Gastroenterol. 2014, 20, 4702–4711. [Google Scholar] [CrossRef]
  63. Mi, Y.; Shi, Q.-Y.; Xu, L.; Shi, R.-F.; Liu, Y.-G.; Li, P.; Shen, F.; Lu, W.; Fan, J.-G. Controlled Attenuation Parameter for Noninvasive Assessment of Hepatic Steatosis Using Fibroscan®: Validation in Chronic Hepatitis B. Dig. Dis. Sci. 2014, 60, 243–251. [Google Scholar] [CrossRef] [PubMed]
  64. Ratchatasettakul, K.; Rattanasiri, S.; Promson, K.; Sringam, P.; Sobhonslidsuk, A. The inverse effect of meal intake on controlled attenuation parameter and liver stiffness as assessed by transient elastography. BMC Gastroenterol. 2017, 17, 50. [Google Scholar] [CrossRef]
  65. Silva, M.; Moreira, P.C.; Peixoto, A.; Santos, A.L.; Lopes, S.; Goncalves, R.; Pereira, P.; Cardoso, H.; Macedo, G. Effect of Meal Ingestion on Liver Stiffness and Controlled Attenuation Parameter. GE Port. J. Gastroenterol. 2018, 26, 99–104. [Google Scholar] [CrossRef] [PubMed]
  66. Sasso, M.; Audière, S.; Kemgang, A.; Gaouar, F.; Corpechot, C.; Chazouillères, O.; Fournier, C.; Golsztejn, O.; Prince, S.; Menu, Y.; et al. Liver Steatosis Assessed by Controlled Attenuation Parameter (CAP) Measured with the XL Probe of the FibroScan: A Pilot Study Assessing Diagnostic Accuracy. Ultrasound Med. Biol. 2016, 42, 92–103. [Google Scholar] [CrossRef]
  67. Myers, R.P.; Pomier-Layrargues, G.; Kirsch, R.; Pollett, A.; Duarte-Rojo, A.; Wong, D.; Beaton, M.; Levstik, M.; Crotty, P.; Elkashab, M. Feasibility and diagnostic performance of the FibroScan XL probe for liver stiffness measurement in overweight and obese patients. Hepatology 2011, 55, 199–208. [Google Scholar] [CrossRef]
  68. Wong, G.L.-H.; Vergniol, J.; Lo, P.; Wong, V.W.-S.; Foucher, J.; Le Bail, B.; Choi, P.C.-L.; Chermak, F.; Leung, K.-S.; Merrouche, W.; et al. Non-invasive assessment of liver fibrosis with transient elastography (FibroScan®): Applying the cut-offs of M probe to XL probe. Ann. Hepatol. 2013, 12, 402–412. [Google Scholar] [CrossRef]
  69. Şirli, R.; Sporea, I.; Deleanu, A.; Culcea, L.; Szilaski, M.; Popescu, A.; Dănilă, M. Comparison between the M and XL probes for liver fibrosis assessment by Transient Elastography. Med Ultrason. 2014, 16, 119–122. [Google Scholar] [CrossRef] [PubMed]
  70. Caussy, C.; Brissot, J.; Singh, S.; Bassirian, S.; Hernandez, C.; Bettencourt, R.; Rizo, E.; Richards, L.; Sirlin, C.B.; Loomba, R. Prospective, Same-Day, Direct Comparison of Controlled Attenuation Parameter with the M vs. the XL Probe in Patients with Nonalcoholic Fatty Liver Disease, Using Magnetic Resonance Imaging–Proton Density Fat Fraction as the Standard. Clin. Gastroenterol. Hepatol. 2020, 18, 1842–1850. [Google Scholar] [CrossRef]
  71. Chan, W.-K.; Mustapha, N.R.N.; Mahadeva, S.; Wong, V.W.-S.; Cheng, J.Y.-K.; Wong, G.L.H. Can the same controlled attenuation parameter cut-offs be used for M and XL probes for diagnosing hepatic steatosis? J. Gastroenterol. Hepatol. 2018, 33, 1787–1794. [Google Scholar] [CrossRef] [PubMed]
  72. Sumida, Y.; Yoneda, M.; Seko, Y.; Ishiba, H.; Hara, T.; Toyoda, H.; Yasuda, S.; Kumada, T.; Hayashi, H.; Kobayashi, T.; et al. Surveillance of Hepatocellular Carcinoma in Nonalcoholic Fatty Liver Disease. Diagnostics 2020, 10, 579. [Google Scholar] [CrossRef] [PubMed]
Table 1. Diagnostic accuracy for liver fibrosis in patients with NAFLD.
Table 1. Diagnostic accuracy for liver fibrosis in patients with NAFLD.
AuthorYearNProbeAUROC (Prevalence (%))
Stage ≥1Stage ≥2Stage ≥3Stage 4
Yoneda et al. [20]200767M0.881 (78)0.876 (49)0.914 (24)0.997 (7)
Yoneda et al. [21]200897M0.927 (81)0.865 (53)0.904 (28)0.991 (9)
Nobili et al. [22]200850M0.97 (78)0.99 (24)1.00 (10)-
Wong et al. [23]2010246M-0.84 (41)0.93 (23)0.95 (10)
Lupsor et al. [24]201072M0.879 (65)0.789 (25)0.978 (7)-
Friedrich-Rust et al. [25]201050M-0.79 (30)0.75 (24)0.91 (6)
50XL-0.81 (30)0.84 (24)0.95 (6)
Petta et al. [26]2011146M-0.794 (47)0.870 (23)-
Friedrich-Rust et al. [27]201237M-0.80 (n.d.)0.73 (n.d.)0.93 (n.d.)
43XL-0.82 (n.d.)0.84 (n.d.)0.93 (n.d.)
Wong et al. [28]2012156M-0.83 (42)0.87 (27)0.89 (10)
184XL-0.80 (45)0.85 (29)0.91 (13)
Kumar et al. [29]2013205M0.82 (84)0.85 (68)0.94 (55)0.96 (46)
Pathik et al. [30]2015110M--0.91 (35)-
Imajo et al. [31]2016127M0.78 (n.d.)0.82 (n.d.)0.88 (n.d.)0.92 (n.d.)
Chan et al. [19]201757M0.88 (60)0.95 (23)0.97 (14)0.97 (5)
57XL0.87 (60)0.90 (23)0.95 (14)0.98 (5)
Eddowes et al. [32]2019373M/XL-0.77 (60)0.80 (38)0.89 (9)
Oeda et al. [33]202096M-0.777 (52)0.836 (27)0.971 (5)
96XL-0.787 (52)0.806 (27)0.970 (5)
Cardoso et al. [34]202081M-0.82 (19)--
81XL-0.80 (19)--
Abbreviations: AUROC, area under the receiver operating characteristic curve; NAFLD, non-alcoholic fatty liver disease; N, the number of patients; n.d., not described.
Table 2. Diagnostic accuracy for liver steatosis in patients with NAFLD.
Table 2. Diagnostic accuracy for liver steatosis in patients with NAFLD.
AuthorYearNProbeAUROC (Prevalence (%))
Score ≥1Score ≥2Score 3
Chan et al. [53]2014101M0.97 (87)0.86 (64)0.75 (14)
Imajo et al. [31]2016127M0.88 (n.d.)0.73 (n.d.)0.70 (n.d.)
Chan et al. [19]201757M0.94 (98)0.80 (75)0.69 (26)
57XL0.97 (98)0.81 (75)0.67 (26)
Eddowes et al. [32]2019380M/XL0.87 (80)0.77 (64)0.70 (36)
Darweesh et al. [54]201960M-0.77 (63)0.92 (22)
Oeda at al [33]2020100M-0.638 (44)0.687 (19)
100XL-0.680 (44)0.713 (19)
Cardoso et al. [34]202081M-0.75 (73)0.83 (23)
81XL-0.76 (73)0.82 (23)
Abbreviations: NAFLD, non-alcoholic fatty liver disease; N, the number of patients; n.d., not described.
Table 3. Factors affecting CAP measurements.
Table 3. Factors affecting CAP measurements.
Etiology[53] *[56] *[57] *[59] *[60] *[61] *[62] *[63] *
NAFLDNAFLD
Others
NAFLD
HBV
HCV
Others
HCVNAFLD
HBV
HCV
NAFLD
HBV
HCV
Others
NAFLD
HBV
HBV
Age ×× ×
Sex ×× ×
Body mass index
Liver steatosis
Inflammation ××××× ×
Liver fibrosis ×××××
AST× ××
ALT× × ×××
Total cholesterol× × ×××
Triglyceride ×××
Fasting glucose× ×
* Reference number; ○: significant and independent factor; △: factor excluded by the stepwise regression analysis; ×: not a significant factor. Abbreviations: CAP, controlled attenuation parameter; AST, aspartate aminotransferase; ALT, alanine aminotransferase; NAFLD, non-alcoholic fatty liver disease; HBV, hepatitis B virus; HCV, hepatitis C virus.
Table 4. Associations between factors affecting the LSM or CAP *.
Table 4. Associations between factors affecting the LSM or CAP *.
FactorsLSMCAP
Liver fibrosis
Inflammation
Venous pressure
Cholestasis
Amyloidosis
Food intake
Liver steatosis
Body mass index
↑: increased FibroScan measurements; →: did not affect FibroScan measurements, →: not enough evidence. Abbreviations: CAP, controlled attenuation parameter; LSM, liver stiffness measurement. * As described in Section 2.3 and Section 3.3 and FibroScan measurements.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Back to TopTop