Shear wave elastography for liver fibrosis in chronic hepatitis B: Adapting the cut-offs to alanine aminotransferase levels improves accuracy
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To determine and validate alanine aminotransferase (ALT)-adapted dual cut-offs of liver stiffness measurements (LSMs) for assessing liver fibrosis with two-dimensional shear wave elastography (2D-SWE) in patients with chronic hepatitis B (CHB) infection.
Patients with CHB infection who underwent liver biopsy to assess liver fibrosis were consecutively included. 2D-SWE confirmation thresholds with a positive likelihood ratio ≥10 and 2D-SWE exclusion thresholds with a negative likelihood ratio ≤0.1 were identified to rule in or rule out significant fibrosis and cirrhosis, respectively.
The first 515 patients (index cohort) and the next 421 patients (validation cohort) were included in the final analysis. The low and high cut-offs to rule out and rule in patients with significant fibrosis (≥ F2) were 5.4 kPa and 9.0 kPa, respectively, in patients with ALT levels ≤ 2 × the upper limit of normal (ULN) and 7.1 kPa and 11.2 kPa in patients with ALT levels > 2 × ULN. For cirrhosis (F4), the corresponding values were 8.1 kPa and 12.3 kPa in patients with ALT levels ≤ 2 × ULN and 11.9 kPa and 24.7 kPa in patients with ALT levels > 2 × ULN. The dual cut-off values showed an overall accuracy of more than 90% for diagnosis of the presence or absence of significant fibrosis and cirrhosis in the index and validation cohorts. There were no significant differences in the accuracy values between the cohorts (all p>0.05).
The ALT-adapted dual cut-offs of LSMs showed high accuracy for diagnosis of the presence or absence of significant fibrosis and cirrhosis in patients with CHB infection.
• The ALT-adapted dual cut-off values of LSMs showed high accuracy for diagnosis of the presence or absence of significant fibrosis and cirrhosis.
• ALT levels did not influence the overall diagnostic accuracy for predicting significant fibrosis and cirrhosis.
• The ALT-adapted dual cut-offs in patients with ALT levels > 2 × ULN were markedly higher than those in patients with ALT levels ≤ 2 × ULN.
KeywordsElasticity imaging techniques Ultrasonography Hepatitis B Alanine transaminase Sensitivity and specificity
Two-dimensional shear wave elastography
Aspartate aminotransferase-to-platelet index
Areas under the ROC curves
Body mass index
Chronic hepatitis B
Positive likelihood ratio
Negative likelihood ratio
Liver stiffness measurement
Receiver operating characteristic
Region of interest
Upper limit of normal
The authors wish to thank Cai-Xia Zhang, PhD (School of Public Health, Sun Yat-Sen University) for her statistical advice.
This study has received funding by National Natural Science Foundation of China (Grants 81601503 and 81471672) and Science, Technology and Innovation Commission of Shenzhen Municipality (Grant JCY J20170307161018414).
Compliance with ethical standards
The scientific guarantor of this publication is Rong-Qin Zheng.
Conflict of interest
The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.
Statistics and biometry
Cai-Xia Zhang, PhD (School of Public Health, Sun Yat-Sen University) kindly provided statistical advice for this manuscript.
Written informed consent was obtained from all subjects (patients) in this study.
Institutional Review Board approval was obtained.
Study subjects or cohorts overlap
Some study subjects or cohorts have been previously reported in two articles entitled "Comparison of 2-D shear wave elastography and transient elastography for assessing liver fibrosis in chronic hepatitis B" and “Diagnostic accuracy of two-dimensional shear wave elastography for the non-invasive staging of hepatic fibrosis in chronic hepatitis B: a cohort study with internal validation”.
• diagnostic or prognostic study
• performed at one institution
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