Liver, Pancreas and Biliary TractAST to Platelet Ratio Index and fibrosis 4 calculator scores for non-invasive assessment of hepatic fibrosis in patients with non-alcoholic fatty liver disease
Introduction
Nonalcoholic fatty liver disease (NAFLD) is emerging in recent years as the most prevalent cause for chronic liver disease [1]. NAFLD is also the most common etiology for cryptogenic cirrhosis [2], which may progress to liver failure and hepatocellular carcinoma in a substantial number of patients [3]. While patients with NAFLD who already have advanced fibrosis or cirrhosis are prone to develop severe complications, patients with simple steatosis usually run a benign course and do not appear to have increased mortality as compared to the general population [4]. Therefore, it is important to assess the degree of liver fibrosis in NAFLD patients for surveillance as well as for prognostic purposes [5].
Percutaneous liver biopsy is the gold standard for assessment of the degree of liver inflammation and fibrosis. However, limitations of this procedure include cost, risk of serious complications, a substantial rate of sampling error and observer variations [6]. In recent years, methods for indirect assessment of liver fibrosis by non-invasive means have been introduced [7]. Scoring systems, based on laboratory tests and patients’ medical history, are simple and non-expensive alternative methods for determining the extent of liver fibrosis. Furthermore, the uneven distribution of fibrosis throughout the liver in NAFLD might result in biopsy related sampling variability, suggesting that non biopsy-based scoring systems may represent a more accurate reflection of global liver fibrosis [8].
The AST-to-Platelet Ratio Index (APRI) and fibrosis 4 calculator (FIB-4) score were originally designed for patients with chronic hepatitis C virus (HCV) infection, but several studies have demonstrated reasonable utility in assessing fibrosis in NAFLD patients, as well [9], [10]. In contrast to the NAFLD-dedicated NAFLD fibrosis score (NFS), APRI score is not based on clinical or epidemiological parameters but is rather relied on patients’ AST level and platelets count [11]. The frequent mild inflammatory activity in patients with NAFLD [12] may result in lower AST levels as compared to HCV patients, and therefore disproportionally low numeric APRI score for a given fibrosis stage. On the other hand, a recent study found portal hypertension in 12% of patients with NAFLD who had no or only mild fibrosis on liver biopsy [13]. This suggests that a fraction of NAFLD patients might develop thrombocytopenia without advanced fibrosis, resulting in a disproportionally high APRI score relative to their actual fibrosis stage.
The aim of this study was to evaluate the performance of APRI and FIB-4 scores in predicting the liver fibrosis stage in NAFLD patients and to compare the sensitivity and specificity of those scores in NAFLD patients to those in patients with chronic HCV infection.
Section snippets
Study design
This retrospective study was approved by the local institutional review board (IRB) according to the local regulations. All documented liver biopsy results performed from August 2005 to December 2012 and patients’ demographic, clinical and laboratory data, obtained from their electronic records, were reviewed. After an extensive review of the patients’ medical records, only those with unequivocal diagnosis of NAFLD or chronic HCV infection were included in the analysis.
In NAFLD patients, other
Patients’ characteristics according to their liver fibrosis stage
1479 liver biopsies, performed at our institute from August 2005 to December 2012, were reviewed. 153 patients with biopsy-proven NAFLD and 297 patients with biopsy-proven HCV infection were included in the current analysis (Fig. 1). Table 1 outlines the baseline characteristics of the study population. Advanced fibrosis was found in 32 (20.9%) and 52 (17.5%) of the NAFLD and HCV patients, respectively, as determined by liver histology.
As expected, in both groups patients with advanced fibrosis
Discussion
In this study, based on a large cohort of HCV and NAFLD patients with all stages of hepatic fibrosis, we found that APRI score is a good predictor for advanced fibrosis among NAFLD patients, although its performance is modestly inferior as compared to patients with chronic HCV infection. In addition, our data suggest that APRI score is not a good discriminator between intermediate fibrosis stages in patients with NAFLD as compared to its performance in patients with chronic HCV infection. A low
Conflicts of interest
None declared.
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