Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA.
Hepatology. 2011 Jun;53(6):1874-82. doi: 10.1002/hep.24268. Epub 2011 May 14.
Since the initial description of nonalcoholic steatohepatitis (NASH), several sets of pathologic criteria for its diagnosis have been proposed. However, their interprotocol agreement and ability to predict long-term liver-related mortality (LRM) have not been demonstrated. In this study, we examined patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD) for whom liver biopsy slides and clinical and mortality data were available. Liver biopsy samples were evaluated for a number of pathologic features and were classified according to the presence or absence of NASH by (1) the original criteria for NAFLD subtypes, (2) the nonalcoholic fatty liver disease activity score (NAS), (3) the Brunt criteria, and (4) the current study's criteria. All NASH diagnostic criteria and individual pathologic features were tested for agreement and for their independent associations with LRM, which were determined with a Cox proportional hazards model. Two hundred fifty-seven NAFLD patients with complete data were included. The diagnoses of NASH by the original NAFLD subtypes and by the current study's definition of NASH were in almost perfect agreement (κ = 0.896). However, their agreement was moderate with NAS (κ = 0.470 and κ = 0.511, respectively) and only fair to moderate with the Brunt criteria (κ = 0.365 and κ = 0.441, respectively). Furthermore, the agreement of the Brunt criteria with NAS was relatively poor (κ = 0.178). During the follow-up (median = 146 months), 31% of the patients died (9% were LRM). After we controlled for confounders, a diagnosis of NASH by the original criteria for NAFLD subtypes [adjusted hazard ratio = 9.94 (95% confidence interval = 1.28-77.08)] demonstrated the best independent association with LRM. Among the individual pathologic features, advanced fibrosis showed the best independent association with LRM [adjusted hazard ratio = 5.68 (95% confidence interval = 1.50-21.45)].
The original criteria for NAFLD subtypes and the current study's criteria for NASH were in almost perfect agreement, but their level of agreement with the NAS and Brunt criteria was lower. A diagnosis of NASH by the original criteria for NAFLD subtypes demonstrated the best predictability for LRM in NAFLD patients.
自非酒精性脂肪性肝炎（NASH）最初描述以来，已经提出了几套用于其诊断的病理标准。然而，它们之间的协议和预测长期与肝脏相关死亡率（LRM）的能力尚未得到证实。在这项研究中，我们检查了经活检证实的非酒精性脂肪性肝病（NAFLD）患者，这些患者的肝活检切片和临床及死亡率数据可用。根据存在或不存在 NASH，对肝活检样本进行了多种病理特征的评估，并根据（1）NAFLD 亚型的原始标准，（2）非酒精性脂肪性肝病活动评分（NAS），（3）Brunt 标准和（4）本研究的标准进行分类。所有 NASH 诊断标准和各个病理特征均进行了一致性测试，并通过 Cox 比例风险模型确定了它们与 LRM 的独立关联。纳入了 257 例具有完整数据的 NAFLD 患者。根据原始的 NAFLD 亚型和本研究中 NASH 的定义，NASH 的诊断几乎完全一致（κ = 0.896）。但是，它们与 NAS 的一致性中等（κ = 0.470 和 κ = 0.511），与 Brunt 标准的一致性仅为中等（κ = 0.365 和 κ = 0.441）。此外，Brunt 标准与 NAS 的一致性相对较差（κ = 0.178）。在随访期间（中位数 = 146 个月），31％的患者死亡（9％为 LRM）。在控制混杂因素后，NAFLD 亚型的原始标准诊断为 NASH [校正后的危险比= 9.94（95％置信区间= 1.28-77.08）]，与 LRM 的相关性最好。在各个病理特征中，晚期纤维化与 LRM 的相关性最好[校正后的危险比= 5.68（95％置信区间= 1.50-21.45）]。
NAFLD 亚型的原始标准和本研究中 NASH 的标准几乎完全一致，但它们与 NAS 和 Brunt 标准的一致性较低。NAFLD 患者中，NAFLD 亚型的原始标准诊断为 NASH，对 LRM 的预测性最佳。
