- Email: [email protected]
Non-invasive markers of liver fibrosis: How to use them in clinical practice?
Letters to the Editor / Journal of Hepatology 46 (2007) 528–530
529
Fig. 1. Impact of the use of non-invasive markers on the need for liver biopsy in patients with chronic hepatitis C in France according to the type of practice.
[4] [5] [6] [7]
Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350. Castera L, Pawlotsky JM. Noninvasive diagnosis of liver fibrosis in patients with chronic hepatitis C. MedGenMed 2005;7:39. EASL International Consensus Conference on hepatitis C. Paris, 26-27 February 1999. Consensus statement. J Hepatol 1999;31:3–8. NIH Consensus Statement on Management of Hepatitis C: 2002. Hepatology 2002;36:S3–20. Sebastiani G, Alberti A. Non invasive fibrosis biomarkers reduce but not substitute the need for liver biopsy. World J Gastroenterol 2006;12:3682–3694.
Laurent Castera Services d’He´pato-Gastroente´rologie, Centre Hosiptalier, Universitaire de Bordeaux, Bordeaux, France E-mail address: [email protected]
Jacques Denis Service d’He´pato-Gastroente´rologie, Centre Hospitalier Sud Francilien, Corbeil, France Gerard Babany Produits Roche, Neuilly sur Seine, France Franc¸oise Roudot-Thoraval De´partement de Sante´ Publique, AP-HP, Hoˆpital Henri Mondor, Cre´teil, France
doi: 10.1016/j.jhep.2006.12.002
Non-invasive markers of liver fibrosis: How to use them in clinical practice? To the Editor: We fully agree with Castera et al. [1] regarding the need to develop and validate guidelines for the use of non-invasive markers of liver fibrosis in clinical practice. Castera et al. referred to a nationwide survey among French hepatologists, indicating that in France, Fibrotest is the most used marker, followed by Fibroscan and hyaluronan.
Liver biopsy was still performed systematically by only 4% of respondants. Liver biopsy was considered still necessary in case of discrepancy between Fibroscan and Fibrotest. Interestingly, guidelines for the use of non-invasive markers in clinical practice were required by 95% of respondants. Similarly, a recent survey assessing the consensus among Italian hepatologists about when and
530
Letters to the Editor / Journal of Hepatology 46 (2007) 528–530
how to take a liver biopsy in chronic hepatitis C showed a great divergence in the management of the same group of patients, indicating the need to better define the role of biopsy and of non-invasive markers [2]. Our studies describing sequential algorithms based on the use of APRI, Fibrotest [3,4] clearly indicate that liver biopsy cannot be completely avoided when a precise definition of the stage of liver fibrosis is needed in patients chronically infected with HCV or HBV. This may still be essential for treatment decisions in special populations of patients, such as those with high viraemia, or with contraindications, with normal ALT or not highly motivated. In these cases, as well as in many others, the distinction among minimal, intermediate or advanced fibrosis may greatly help in directing management. Available data indicate that non-invasive markers of fibrosis and liver biopsy should be considered as agonists and not antagonists towards the common goal of correctly classifying the stage of liver fibrosis [5]. This is also true for the combined use of Fibrotest and Fibroscan, as reported by Castera et al. [6]. We completely agree with these authors that the most accurate non-invasive markers should be used as first line assessment, limiting liver biopsy to the cases in which they do not agree or have low predictive value. Priority should be given to large scale validation studies of these algorithms in different patient populations inclusive of all major etiologies of chronic liver disease and most frequent cofactors which may affect the diagnostic performance of fibrosis markers.
References [1] Castera L, Denis J, Babany G, Roudot-Thoraval F. Evolving practices of non-invasive markers of liver fibrosis in patients with chronic hepatitis C in France: Time for new guidelines? J Hepatol 2007;46:528–529. [2] Almasio PL, Niero M, Angioli D, Ascione A, Gullini S, Minoli G, et al. Experts’ opinions on the role of liver biopsy in HCV infection: a Delphi survey by the Italian Association of Hospital Gastroenterologists (A.I.G.O.). J Hepatol 2005;43:381–387. [3] Sebastiani G, Vario A, Guido M, Noventa F, Plebani M, Pistis R, et al. Stepwise combination algorithms of non-invasive markers to diagnose significant fibrosis in chronic hepatitis C. J Hepatol 2006;44:686–693. [4] Sebastiani G, Vario A, Guido M, Alberti A. Sequential algorithms combining non-invasive markers and biopsy for the assessment of liver fibrosis in chronic hepatitis B. World J Gastroenterol, in press. [5] Sebastiani G, Alberti A. Non invasive fibrosis biomarkers reduce but not substitute the need for liver biopsy. World J Gastroenterol 2006;12:3682–3694. [6] Castera L, Vergniol J, Foucher J, Le Bail B, Chanteloup E, Haaser M, et al. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350.
Giada Sebastiani Alfredo Alberti Department of Clinical and Experimental Medicine, University of Padova, and Venetian Institute of Molecular Medicine, Padova, Italy E-mail address: [email protected] (A. Alberti) doi: 10.1016/j.jhep.2006.12.003
529
Fig. 1. Impact of the use of non-invasive markers on the need for liver biopsy in patients with chronic hepatitis C in France according to the type of practice.
[4] [5] [6] [7]
Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350. Castera L, Pawlotsky JM. Noninvasive diagnosis of liver fibrosis in patients with chronic hepatitis C. MedGenMed 2005;7:39. EASL International Consensus Conference on hepatitis C. Paris, 26-27 February 1999. Consensus statement. J Hepatol 1999;31:3–8. NIH Consensus Statement on Management of Hepatitis C: 2002. Hepatology 2002;36:S3–20. Sebastiani G, Alberti A. Non invasive fibrosis biomarkers reduce but not substitute the need for liver biopsy. World J Gastroenterol 2006;12:3682–3694.
Laurent Castera Services d’He´pato-Gastroente´rologie, Centre Hosiptalier, Universitaire de Bordeaux, Bordeaux, France E-mail address: [email protected]
Jacques Denis Service d’He´pato-Gastroente´rologie, Centre Hospitalier Sud Francilien, Corbeil, France Gerard Babany Produits Roche, Neuilly sur Seine, France Franc¸oise Roudot-Thoraval De´partement de Sante´ Publique, AP-HP, Hoˆpital Henri Mondor, Cre´teil, France
doi: 10.1016/j.jhep.2006.12.002
Non-invasive markers of liver fibrosis: How to use them in clinical practice? To the Editor: We fully agree with Castera et al. [1] regarding the need to develop and validate guidelines for the use of non-invasive markers of liver fibrosis in clinical practice. Castera et al. referred to a nationwide survey among French hepatologists, indicating that in France, Fibrotest is the most used marker, followed by Fibroscan and hyaluronan.
Liver biopsy was still performed systematically by only 4% of respondants. Liver biopsy was considered still necessary in case of discrepancy between Fibroscan and Fibrotest. Interestingly, guidelines for the use of non-invasive markers in clinical practice were required by 95% of respondants. Similarly, a recent survey assessing the consensus among Italian hepatologists about when and
530
Letters to the Editor / Journal of Hepatology 46 (2007) 528–530
how to take a liver biopsy in chronic hepatitis C showed a great divergence in the management of the same group of patients, indicating the need to better define the role of biopsy and of non-invasive markers [2]. Our studies describing sequential algorithms based on the use of APRI, Fibrotest [3,4] clearly indicate that liver biopsy cannot be completely avoided when a precise definition of the stage of liver fibrosis is needed in patients chronically infected with HCV or HBV. This may still be essential for treatment decisions in special populations of patients, such as those with high viraemia, or with contraindications, with normal ALT or not highly motivated. In these cases, as well as in many others, the distinction among minimal, intermediate or advanced fibrosis may greatly help in directing management. Available data indicate that non-invasive markers of fibrosis and liver biopsy should be considered as agonists and not antagonists towards the common goal of correctly classifying the stage of liver fibrosis [5]. This is also true for the combined use of Fibrotest and Fibroscan, as reported by Castera et al. [6]. We completely agree with these authors that the most accurate non-invasive markers should be used as first line assessment, limiting liver biopsy to the cases in which they do not agree or have low predictive value. Priority should be given to large scale validation studies of these algorithms in different patient populations inclusive of all major etiologies of chronic liver disease and most frequent cofactors which may affect the diagnostic performance of fibrosis markers.
References [1] Castera L, Denis J, Babany G, Roudot-Thoraval F. Evolving practices of non-invasive markers of liver fibrosis in patients with chronic hepatitis C in France: Time for new guidelines? J Hepatol 2007;46:528–529. [2] Almasio PL, Niero M, Angioli D, Ascione A, Gullini S, Minoli G, et al. Experts’ opinions on the role of liver biopsy in HCV infection: a Delphi survey by the Italian Association of Hospital Gastroenterologists (A.I.G.O.). J Hepatol 2005;43:381–387. [3] Sebastiani G, Vario A, Guido M, Noventa F, Plebani M, Pistis R, et al. Stepwise combination algorithms of non-invasive markers to diagnose significant fibrosis in chronic hepatitis C. J Hepatol 2006;44:686–693. [4] Sebastiani G, Vario A, Guido M, Alberti A. Sequential algorithms combining non-invasive markers and biopsy for the assessment of liver fibrosis in chronic hepatitis B. World J Gastroenterol, in press. [5] Sebastiani G, Alberti A. Non invasive fibrosis biomarkers reduce but not substitute the need for liver biopsy. World J Gastroenterol 2006;12:3682–3694. [6] Castera L, Vergniol J, Foucher J, Le Bail B, Chanteloup E, Haaser M, et al. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350.
Giada Sebastiani Alfredo Alberti Department of Clinical and Experimental Medicine, University of Padova, and Venetian Institute of Molecular Medicine, Padova, Italy E-mail address: [email protected] (A. Alberti) doi: 10.1016/j.jhep.2006.12.003