Systematic review: diagnostic accuracy of non-invasive tests for staging liver fibrosis in autoimmune hepatitis
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Background and aims
Non-invasive fibrosis assessment has been highly recommended in many liver diseases. However, comparative diagnostic accuracy of laboratory markers, ultrasound and magnetic resonance elastography (MRE) for fibrosis in autoimmune hepatitis (AIH) patients has not been established.
Medline, Embase and Cochrane Library were searched. Primary outcome was significant fibrosis (SF), advanced fibrosis (AF) and cirrhosis, defined as Metavir stage F ≥ 2, F ≥ 3 and F = 4 according to liver biopsy. Hierarchical summary receiver operating characteristic curve (ROC) model was used to evaluate diagnostic accuracy of non-invasive methods. Summary area under ROC (AUROC) and diagnostic odds ratio (DOR) with 95% confidence interval (CI) were calculated. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess quality of evidence.
Overall, 16 studies with 861 patients were included, comparing aspartate aminotransferase to platelet ratio index (APRI), fibrosis-4 index (FIB-4), aspartate aminotransferase/alanine aminotransferase ratio, transient elastography (TE), acoustic radiation force impulse, shear wave elastography and MRE versus liver biopsy. Among all non-invasive markers, TE had good performance for fibrosis staging. Summary AUROCs and DORs of TE were 0.90 (95% CI 0.87, 0.92) and 23.7, 0.91 (95% CI 0.89, 0.93) and 31.6, 0.89 (95% CI 0.86, 0.92) and 80.5 for staging SF, AF and cirrhosis, whereas APRI and FIB-4 showed poor performance for detecting AF (DOR, 4.6 and 4.7) and cirrhosis (DOR, 5.5 and 12.9).
TE performs well to stage liver fibrosis in patients with AIH, compared with other laboratory non-invasive indexes. Nevertheless, diagnostic accuracy of APRI and FIB-4 is poor.
KeywordsAutoimmune hepatitis Liver fibrosis Non-invasive methods Transient elastography
List of abbreviations
Magnetic resonance elastography
Receiver operating characteristic curve
Summary area under ROC
Diagnostic odds ratio
Aspartate aminotransferase to platelet ratio index
Aspartate aminotransferase/alanine aminotransferase ratio
Acoustic radiation force impulse
Shear wave elastography
American Association for the Study of Liver Diseases
European Association for the Study of the Liver
Platelet count to spleen diameter
Non-alcoholic fatty liver disease
Positive predictive value
Negative predictive value
Quality Assessment of Diagnostic Accuracy Studies-2 scale
The Grading of Recommendations Assessment Development and Evaluation
Positive likelihood ratio
Negative likelihood ratio
Upper limit normal
We are grateful to all cooperating organizations and their staff whose hard work made this study possible. ZRY is supported by the Cambridge Trust and the China Scholarship Council. Thanks to Prof. Jing Hua for supplying cut-off value, sensitivity and specificity of APRI and FIB-4 detecting advanced fibrosis.
SSW and HY designed the study and drafted the manuscript. SSW, NZ, ZYH and JLZ extracted the data, SSW, ZRY, and SYZ evaluated the quality. SSW, ZRY, and SYZ assessed the quality of evidence by GRADE framework. SSW and ZRY analyzed the data. HY and JDJ interpreted the results, incorporated comments for the co-authors and finalized the manuscript. All authors approved the final version of the paper.
This study is funded by Beijing Municipal Administration of Hospitals’ Youth Program (QML20170107) and Beijing Talents Fund (2016000021469G226). The sponsor had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Compliance with ethical standards
Conflict of interest
Shanshan Wu, Zhirong Yang, Jialing Zhou, Na Zeng, Zhiying He, Siyan Zhan, Jidong Jia, and Hong You have no conflict of interests.
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