Hepatology International

, Volume 13, Issue 1, pp 91–101 | Cite as

Systematic review: diagnostic accuracy of non-invasive tests for staging liver fibrosis in autoimmune hepatitis

  • Shanshan Wu
  • Zhirong Yang
  • Jialing Zhou
  • Na Zeng
  • Zhiying He
  • Siyan Zhan
  • Jidong Jia
  • Hong YouEmail author
Original Article


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.


Autoimmune hepatitis Liver fibrosis Non-invasive methods Transient elastography 

List of abbreviations


Autoimmune hepatitis


Magnetic resonance elastography


Significant fibrosis


Advanced fibrosis


Receiver operating characteristic curve


Summary area under ROC


Diagnostic odds ratio


Confidence interval


Aspartate aminotransferase to platelet ratio index


Fibrosis-4 index


Aspartate aminotransferase/alanine aminotransferase ratio


Transient elastography


Acoustic radiation force impulse


Shear wave elastography


Hepatocellular carcinoma


American Association for the Study of Liver Diseases


European Association for the Study of the Liver


Aspartate aminotransferase


Alanine aminotransferase


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.

Financial support

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.

Supplementary material

12072_2018_9907_MOESM1_ESM.docx (179 kb)
Supplementary material 1 (DOCX 180 kb)


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Copyright information

© Asian Pacific Association for the Study of the Liver 2018

Authors and Affiliations

  • Shanshan Wu
    • 1
  • Zhirong Yang
    • 2
    • 3
  • Jialing Zhou
    • 1
  • Na Zeng
    • 1
  • Zhiying He
    • 1
  • Siyan Zhan
    • 4
  • Jidong Jia
    • 1
    • 5
  • Hong You
    • 1
    • 5
    Email author
  1. 1.National Clinical Research Center of Digestive Diseases, Beijing Friendship HospitalCapital Medical UniversityBeijingChina
  2. 2.Primary Care Unit, Department of Public Health and Primary Care, School of Clinical MedicineUniversity of CambridgeCambridgeUK
  3. 3.Department of Population Medicine, Harvard Medical SchoolHarvard Pilgrim Health Care InstituteBostonUSA
  4. 4.Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CentreBeijingChina
  5. 5.Liver Research Center, Beijing Friendship HospitalCapital Medical UniversityBeijingChina

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