Bril Fernando, Godinez Leiva Eddison, Lomonaco Romina, Shrestha Sulav, Kalavalapalli Srilaxmi, Gray Meagan, Cusi Kenneth
Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Florida, Gainesville, FL 32608, USA.
Metab Target Organ Damage. 2022;2. doi: 10.20517/mtod.2022.08. Epub 2022 Jul 18.
The optimal screening strategy for advanced liver fibrosis in overweight and obese patients is unknown. The aim of this study is to compare the performance of different strategies to select patients at high risk of advanced liver fibrosis for screening using non-invasive tools.
All patients underwent: liver H-MRS and percutaneous liver biopsy (in those with nonalcoholic fatty liver disease [NAFLD]). Unique selection strategies were compared to determine the best screening algorithm: (A) A "metabolic approach": selecting patients based on HOMA-IR ≥ 3; (B) A "diabetes approach": selecting only patients with type 2 diabetes; (C) An "imaging approach": selecting patients with hepatic steatosis based on H-MRS; (D) A "liver biochemistry approach": selecting patients with elevated ALT (i.e., ≥ 30 IU/L for males and ≥ 19 IU/L for females); and (E) Universal screening of overweight and obese patients. FIB-4 index, NAFLD fibrosis score, and APRI were applied as screening strategies.
A total of 275 patients were included in the study. Patients with advanced fibrosis ( = 29) were matched for age, gender, ethnicity, and BMI. Selecting patients by ALT elevation provided the most effective strategy, limiting the false positive rate while maintaining the sensitivity compared to universal screening. Selecting patients by any other strategy did not contribute to increasing the sensitivity of the approach and resulted in more false positive results.
Universal screening of overweight/obese patients for advanced fibrosis with non-invasive tools is unwarranted, as selection strategies based on elevated ALT levels lead to the same sensitivity with a lower false positive rate (i.e., fewer patients that would require a liver biopsy or referral to hepatology).
超重和肥胖患者中晚期肝纤维化的最佳筛查策略尚不清楚。本研究的目的是比较不同策略在使用非侵入性工具筛查晚期肝纤维化高危患者时的表现。
所有患者均接受了肝脏氢磁共振波谱分析（H-MRS）和经皮肝活检（针对非酒精性脂肪性肝病[NAFLD]患者）。比较了不同的选择策略以确定最佳筛查算法：（A）“代谢方法”：基于稳态模型评估胰岛素抵抗（HOMA-IR）≥3选择患者；（B）“糖尿病方法”：仅选择2型糖尿病患者；（C）“影像学方法”：基于H-MRS选择肝脂肪变性患者；（D）“肝脏生物化学方法”：选择丙氨酸氨基转移酶（ALT）升高的患者（即男性≥30 IU/L，女性≥19 IU/L）；以及（E）对超重和肥胖患者进行普遍筛查。使用FIB-4指数、NAFLD纤维化评分和天冬氨酸氨基转移酶与血小板比值指数（APRI）作为筛查策略。
本研究共纳入275例患者。对晚期纤维化患者（n = 29）进行了年龄、性别、种族和体重指数匹配。与普遍筛查相比，通过ALT升高选择患者提供了最有效的策略，在保持敏感性的同时限制了假阳性率。通过任何其他策略选择患者均无助于提高该方法的敏感性，且会导致更多假阳性结果。
对超重/肥胖患者使用非侵入性工具进行晚期纤维化的普遍筛查是不必要的，因为基于ALT水平升高的选择策略可导致相同的敏感性，但假阳性率更低（即需要进行肝活检或转诊至肝病科的患者更少）。
