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

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Abstract

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.

Methods

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.

Results

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).

Conclusions

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.

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Abbreviations

AIH:

Autoimmune hepatitis

MRE:

Magnetic resonance elastography

SF:

Significant fibrosis

AF:

Advanced fibrosis

ROC:

Receiver operating characteristic curve

AUROC:

Summary area under ROC

DOR:

Diagnostic odds ratio

CI:

Confidence interval

APRI:

Aspartate aminotransferase to platelet ratio index

FIB-4:

Fibrosis-4 index

AAR:

Aspartate aminotransferase/alanine aminotransferase ratio

TE:

Transient elastography

ARFI:

Acoustic radiation force impulse

SWE:

Shear wave elastography

HCC:

Hepatocellular carcinoma

AASLD:

American Association for the Study of Liver Diseases

EASL:

European Association for the Study of the Liver

AST:

Aspartate aminotransferase

ALT:

Alanine aminotransferase

PC/SD:

Platelet count to spleen diameter

NAFLD:

Non-alcoholic fatty liver disease

PPV:

Positive predictive value

NPV:

Negative predictive value

QUADAS-2:

Quality Assessment of Diagnostic Accuracy Studies-2 scale

GRADE:

The Grading of Recommendations Assessment Development and Evaluation

LR+:

Positive likelihood ratio

LR−:

Negative likelihood ratio

ULN:

Upper limit normal

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Acknowledgements

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.

Funding

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.

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Authors and Affiliations

  1. National Clinical Research Center of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China

    Shanshan Wu, Jialing Zhou, Na Zeng, Zhiying He, Jidong Jia & Hong You

  2. Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, CB18RN, UK

    Zhirong Yang

  3. Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA

    Zhirong Yang

  4. Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, 100191, China

    Siyan Zhan

  5. Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China

    Jidong Jia & Hong You

Authors
  1. Shanshan Wu
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Contributions

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.

Corresponding author

Correspondence to Hong You.

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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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Wu, S., Yang, Z., Zhou, J. et al. Systematic review: diagnostic accuracy of non-invasive tests for staging liver fibrosis in autoimmune hepatitis. Hepatol Int 13, 91–101 (2019). https://doi.org/10.1007/s12072-018-9907-5

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  • DOI: https://doi.org/10.1007/s12072-018-9907-5

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