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Department the Gastroenterology, Loyola University clinical Center, Maywood, IL

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Corresponding Author

Department that Hepatology, Loyola University clinical Center, Maywood, IL


Natasha Von Roenn, M.D., department of Hepatology, Loyola University medical Center, 2160 S. 1st Ave., Mulcahy Bldg., Maywood, IL 60153. E-mail: nvonroenn

Department of Gastroenterology, Loyola University clinical Center, Maywood, IL

Search for an ext papers through this author

Department of Gastroenterology, Loyola University medical Center, Maywood, IL

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Corresponding Author

Department that Hepatology, Loyola University medical Center, Maywood, IL


Natasha Von Roenn, M.D., department of Hepatology, Loyola University medical Center, 2160 S. First Ave., Mulcahy Bldg., Maywood, IL 60153. E-mail: nvonroenn

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MRE magnetic resonance elastography NAFLD nonalcoholic fatty liver disease NASH nonalcoholic steatohepatitis car transient elastography

When defining the term gold standard, the many appropriate an interpretation is “a benchmark test the is the best obtainable under reasonable conditions.”1, 2 once considering this definition, it becomes clear the noninvasive imaging has replaced liver biopsy together the gold standard for review of fibrosis in nonalcoholic fat liver condition (NAFLD).

The NAFLD epidemic is approximated to impact almost a quarter of the worldwide population, with countless high-risk features being particularly prevalent in the united States.3 However, the populace most at danger for poor outcomes is those with nonalcoholic steatohepatitis (NASH), due to the fact that these space the patient at best risk for development to cirrhosis.3, 4 In the joined States, the variety of individuals v NASH is approximated to be an ext than 11 million, and our capacity to delineate which patients through NAFLD have NASH remains poor at present. The long-standing usage of liver enzyme to distinguish these different entities has been debunked and also proved inadequate,4-7 and also despite considerable work in the research realm, no other straightforward serological tests or panels have displayed results convincing enough to usurp the previous gold standard.6, 7 The outdated dogma the liver biopsy gift the gold standard for identifying those in ~ risk among these numerous patients would median extrapolating come this populace the known severe complication rate of 1.1%8 and mortality price of 0.3%.9 If we room to as necessary identify the NAFLD populace most at danger for progression to cirrhosis by means of biopsy, it synchronizes to an overwhelming figures the morbidity and death. When considering the earlier an interpretation of gold standard, it i do not care clear that liver biopsy, because that this purpose and also in this population, can not be thought about “under reasonable conditions” as soon as a noninvasive test has actually been showed noninferior.

Transient elastography (TE) has been a clinically useful also that has the method to replace liver biopsy together the yellow standard. TE has actually high accuracy as soon as identifying patients with F3-F4 fibrosis who space at greater risk because that worse clinical outcomes.10 The many remarkable advantage of dare is that the procedure is noninvasive, without any type of of the complications connected with liver biopsy. In addition, its price is one-fourth of that of liver biopsy, and also it have the right to be excellent in 5 minute in the outpatient setting without any kind of associated pain.11 This also enables this check to it is in done much more frequently, and to be followed over time in patient with higher risk features.

Nevertheless, liver biopsies proceed to be done for confirmation in patients who space at threat for fibrosis/cirrhosis. The most useful factor the we obtain from the biopsy and the resultant NAFLD task score is the level of fibrosis. Return fibrosis is a an outcome of continuous inflammation, the grade of inflammation on biopsy has not been shown to have actually an effect on clinical outcomes. Thus, stage of fibrosis continues to be the only far-reaching information acquired from histology.12 once considering this, it becomes fingerprint that, if we are able come accurately assess the degree of fibrosis there is no invasive measures in patients through NAFLD, we will identify the population at hazard for adverse clinical outcomes there is no the aforementioned complications the biopsy.

Some might use one alternative definition for yellow standard, introduce to the many accurate check without restrictions, and will suggest that liver biopsy is an ext accurate than TE. However, liver biopsy samples 1/50,000th the the entire liver, and thus is vulnerable to poor biopsy size, which can decrease accuracy of staging by 25%.13 research studies have displayed that paired biopsies, from two different locations of the liver, deserve to differ in histological fibrosis staging approximately 40% of the time.14 Also, studies have actually demonstrated far-ranging subjectivity in fibrosis staging, with various pathologists disagreeing ~ above staging approximately 50% of the time.13, 15, 16 These natural flaws in liver biopsy together a way for staging fibrosis in NAFLD have pertained to light only recently and also further demonstrate the require for alternative methods (Table 1).

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advantages Cons
Liver biopsy - current Gold conventional - deserve to determine basic etiology the Fibrosis - pains - Bleeding - Mortality danger - small sample size - Variability - reader dependent accuracy - high value
VC transient elastography - No symptom - 1/4 that the cost - - easily repeated - Operator dependent accuracy - limited by body habitus/ ascites - transformed by infiltrative processes - cheap
MR elastography - No complications - Non-inferior come liver biopsy - leader dependent accuracy - Long process - no standardized - limited space

Magnetic resonance elastography (MRE) is a test the is not yet widely available, however which has an accuracy that fibrosis staging top top par with liver biopsy. In identifying patients with F3-F4 disease, the area under the receiver operation characteristic curve because that MRE is at the really least noninferior come liver biopsy at 0.98.16-20 Although restricted head-to-head studies are available, at least one has presented equivalence in detecting and differentiating between significant fibrosis, serious fibrosis, and also cirrhosis.19 In addition, it has been presented that the price of covenant on fibrosis stage between different radiologists reading MRE is better than the of different pathologists assessing biopsy specimens.17-21 (Table 1)

It is clear that the NAFLD epidemic will proceed to broaden in the coming years, and that liver biopsy is not an ideal methodology for testimonial of this patients. Noninvasive modalities have the right to be used more frequently to follow at-risk patients end time, and be instituted for screening evaluations in the lack of the morbidity that unfortunately comes with liver biopsy. Lastly, MRE has arising data to support its noninferiority come liver biopsy in terms of accuracy in fibrosis staging and, combined with the dramatic risk profile differences, need to be considered a premium test. Return the liver biopsy complication rates show up low ~ above an individual basis, expanding those rates to the massive and also growing populace in need of assessment for liver fibrosis provides it apparent that the risk is unsure when challenged with noninvasive and noninferior alternatives. In our opinion and also for the reasons stated earlier, these noninvasive imaging modalities space the new gold standard for assessment of liver fibrosis in patients through NAFLD.