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Diagnostic Accuracy of Transient Elastography for Detecting Liver Fibrosis After Liver Trannsplantation: A Specific Cut-Off Value Is Really Needed?



Liver transplant recipients often perform liver biopsy (LB), specially in the context of potentially recurring diseases, such as hepatitis C infection. However, the LB has risks of complications, despite being the gold standard. Transient elastography (TE) is a noninvasive method comparable to the LB to evaluate liver fibrosis in various settings, but its accuracy among transplant recipients is not fully understood.


To determine the accuracy of TE in liver transplant recipients compared with LB to successfully predict liver fibrosis.

Patients and Methods

Patients who underwent liver transplantation at Hospital Israelita Albert Einstein from 2010 to 2012 and presented with LB indication were also subjected to TE at the time of LB. The medium value of ten successful measurements was kept as a representative of the liver stiffness. The definition of cut-off points was made to ensure specificity of ≥90 % for all fibrosis stages (F0–F4).


LB was performed in 267 patients. TE was not analyzed in only 8 (3 %) due to an elevated body mass index. The optimal liver stiffness cut-off value and diagnostic performance were 8.1 kPa for F ≥ 1, 12.3 kPa for F ≥ 2, 15.1 for F ≥ 3, and 16.7 for F = 4 for all patients and were 8.1 kPa for F ≥ 1, 12.3 kPa for F ≥ 2, 16.5 for F ≥ 3, and 17.6 for F = 4 for patients with hepatitis C.


TE demonstrated good performance in defining cut-off points for fibrosis on liver histology observed in transplant recipients. The TE can be considered an alternative to LB in post-liver transplantation.

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Area under the curve


Body mass index


Hepatitis C virus


Intraclass correlation coefficient


Liver biopsy


Liver fibrosis


Liver stiffness measurement


Negative likelihood ratio


Negative predictive value


Positive likelihood ratio


Positive predictive value


Receiver operating characteristic


Transient elastography


  1. 1.

    Poynard T, Ratziu V, Bedossa P. Appropriateness of liver biopsy. Can J Gastroenterol. 2000;14:543–548.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Berenguer M, Prieto M, San Juan F, et al. Contribution of donor age to the recent decrease in patient survival among HCV-infected liver transplant recipients. Hepatology. 2002;36:202–210.

    Article  PubMed  Google Scholar 

  3. 3.

    Berenguer M, Lopez-Labrador FX, Wright TL. Hepatitis C and liver transplantation. J Hepatol. 2001;35:666–678.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Maharaj B, Maharaj RJ, Leary WP, et al. Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver. Lancet. 1986;1:523–525.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Garcia-Tsao G, Boyer JL. Outpatient liver biopsy: how safe is it? Ann Intern Med. 1993;118:150–153.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Bedossa P, Dargère D, Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C. Hepatology. 2003;38:1449–1457.

    Article  PubMed  Google Scholar 

  7. 7.

    Regev A, Berho M, Jeffers LJ, et al. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection. Am J Gastroenterol. 2002;97:2614–2618.

    Article  PubMed  Google Scholar 

  8. 8.

    Abdi W, Millan JC, Mezey E. Sampling variability on percutaneous liver biopsy. Arch Intern Med. 1979;139:667–669.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Metwally MA, Zein CO, Zein NN. Predictors and noninvasive identification of severe liver fibrosis in patients with chronic hepatitis C. Dig Dis Sci. 2007;52:582–588. doi:10.1007/s10620-006-9366-z.

    Article  PubMed  Google Scholar 

  10. 10.

    Imbert-Bismut F, Messous D, Thibault V, et al. Intra-laboratory analytical variability of biochemical markers of fibrosis (Fibrotest) and activity (ActiTest) and references ranges in healthy blood donors. Clin Chem Lab Med. 2004;42:323–333.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Poynard T, Munteanu M, Imbert-Bismut F, et al. Prospective analysis of discordant results between biochemical markers and biopsy in patients with chronic hepatitis C. Clin Chem. 2004;50:1344–1355.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Friedrich-Rust M, Ong M-F, Herrmann E, et al. Real-time elastography for noinvasive assessment of liver fibrosis in chronic viral hepatitis. AJR Am J Roentgenol. 2007;188:758–764.

    Article  PubMed  Google Scholar 

  13. 13.

    Barrault C, Roudot-Thoravalb F, Tran Van Nhieuc J, et al. Non-invasive assessment of liver graft fibrosis by transient elastography after liver transplantation. Clin Res Hepatol Gastroenterol. 2013;. doi:10.1016/j.clinre.2012.11.003.

    PubMed  Google Scholar 

  14. 14.

    Beckebaum S, Iacob S, Klein CG, et al. Assessment of allograft fibrosis by transient elastography and noninvasive biomarker scoring systems in liver transplant patients. Transplantation. 2010;2010:89.

    Google Scholar 

  15. 15.

    Sandrin L, Fourquet B, Hasquenoph JM, et al. Transient elastography: a new non-invasive method for assessment of hepatic fibrosis. Ultrasound Med Biol. 2003;29:1705–1713.

    Article  PubMed  Google Scholar 

  16. 16.

    Fraquelli M, Rigamonti C, Casazza G, et al. Reproducibility of transient elastography in the evaluation of liver fibrosis in patient with chronic liver disease. Gut. 2007;56:968–973.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Konate A, Boursier J, Reaud S, et al. Liver stiffness measurement by transient elastography: predictive factors of accuracy, success and reproducibility. Hepatology. 2006;44:452A.

    Google Scholar 

  18. 18.

    Harada N, Soejima Y, Taketomi A, et al. Assessment of graft fibrosis by transient elastography in patients with recurrent hepatitis C after living donor liver transplantation. Transplantation. 2008;85:69–74.

    Article  PubMed  Google Scholar 

  19. 19.

    Bedossa P, Poynard T. An algorithm for the grading of activity in chronic hepatitis C. The METAVIR Cooperative Study Group. Hepatology. 1996;24:289.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Altman DG. Practical Statistics for Medical Research. London: Chapman & Hall; 1991:394–401.

    Google Scholar 

  21. 21.

    Szklo R, Nieto FJ. Epidemiology Beyond the Basis. Annapolis: Aspen publications; 2000:343–404.

    Google Scholar 

  22. 22.

    Fraquelli M, Rigamonti C. Diagnosis of cirrhosis by transient elastography: what is hidden behind misleading results. Hepatology. 2006;44:1511.

    Article  Google Scholar 

  23. 23.

    Ziol M, Handra-Luca A, Kettaneh A, et al. Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C. Hepatology. 2005;41:48–54.

    Article  PubMed  Google Scholar 

  24. 24.

    Carrion JA, Navasa M, Bosch J, et al. Transient elastography for diagnosis of advanced fibrosis and portal hypertension in patients with hepatitis C recurrence after liver transplant. Liver Transpl.. 2006;12:1791–1798.

    Article  PubMed  Google Scholar 

  25. 25.

    Cholongitas E, Tsochatzis E, Goulis J, et al. Noninvasive tests for evaluation for fibrosis in HCV recurrence after liver transplantation: a systematic review. Transpl Int. 2010;23:861–870.

    Article  PubMed  Google Scholar 

  26. 26.

    Carrión JÁ, Torres J, Crespo G, et al. Liver stiffness identifies two different patterns of fibrosis progression in patients with hepatitis C virus recurrence after liver transplantation. Hepatology. 2010;51:23–34.

    Article  PubMed  Google Scholar 

  27. 27.

    Rigamonti C, Donato MF, Fraquelli M, et al. Transient elastography early predicts progressive recurrent hepatitis C after liver transplantation. Journal of Hepatology. 2010;52:S171.

    Article  Google Scholar 

  28. 28.

    Kamphues C, Lotz K, Rocken C, et al. Chances and limitations of non-invasive tests in the assessment of liver fibrosis in liver transplant patients. Clin Transpl. 2010;24:652–659.

    Article  Google Scholar 

  29. 29.

    Corradi F, Piscaglia F, Flori S, et al. Assessment of liver fibrosis in transplant recipients with recurrent HCV infection: usefulness of transient elastography. Dig Liver Dis. 2009;41:217–225.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Lee SH, Joo DJ, Kim SU, et al. Graft function measured by transient elastography in living donor liver transplantation: preliminary. Transpl Proc. 2013;45:3028–3031.

    CAS  Article  Google Scholar 

  31. 31.

    Poynard T, Halfon P, Castera L, et al. Standardization of ROC curve areas for diagnostic evaluation of liver fibrosis markers based on prevalences of fibrosis stages. Clin Chem.. 2007;53:1615–1622.

    CAS  Article  PubMed  Google Scholar 

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The authors thank Elivane da Silva Victor, Ph.D., for assistance with the statistical analysis. The liver transplantation unit of the Einstein Transplantation Program is supported by the Programa de Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS) as a result of a partnership between the Sociedade Israelita Brasileira Albert Einstein and the Brazilian Ministry of Health.

Author’s contribution

Dr. Della-Guardia contributed to design, data collection, analysis, writing, and review of the manuscript. Dr. Evangelista and Dr. Felga collected the data. Dr. Marins helped in histological analysis. Drs. Almeida and Salvalaggio contributed to review of the data and manuscript.

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Corresponding author

Correspondence to B. Della-Guardia.

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The authors do not have any commercial and financial connection that can pose a conflict of interest to the findings of this manuscript.

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Della-Guardia, B., Evangelista, A.S., Felga, G.E. et al. Diagnostic Accuracy of Transient Elastography for Detecting Liver Fibrosis After Liver Trannsplantation: A Specific Cut-Off Value Is Really Needed?. Dig Dis Sci 62, 264–272 (2017).

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  • Transient elastography
  • Liver biopsy
  • Liver transplantation