Noninvasive Alternatives to Assess Liver Fibrosis: Ready for Prime Time?

William F. Balistreri, MD


December 02, 2014

In This Article

A Common Clinical Scenario

A healthy, asymptomatic 45-year-old woman with newly diagnosed hepatitis C virus (HCV) infection presents for consultation. Her questions relate not only to treatment options but also to her prognosis: "How much damage has the virus caused?" "Is my liver scarred?" She is informed that despite an unremarkable physical examination, the gold standard for determining the extent of fibrosis is liver biopsy. Having researched her diagnosis, the patient expresses her understanding but has valid concerns that this invasive procedure is subject to not only sampling/interpretation error but also, albeit rarely, potentially life-threatening procedure-related complications. She asks, "Is there a noninvasive way to determine the extent of scarring?"

This is an increasingly common clinical scenario owing to various factors.

Awareness of HCV has increased since the recent Centers for Disease Control and Prevention recommendations that everyone in the baby boomer generation undergo a one-time screening test.[1] This is a major advance in public health, but it brings the potential of discovering hundreds of thousands of infected persons.[2] In addition, widespread excitement has been generated by the emergence of new HCV antivirals that offer a high probability of a cure.[3]

Along with these developments in HCV, there is also the reality that the global epidemic of obesity will bring an increasing number of patients with fatty liver disease to our offices.[4]

The flood of patients with liver disease will challenge clinicians to determine the prognosis and eligibility for treatment and to gauge the response to any intervention.

Thus, there is significant interest in the development and validation of noninvasive alternatives to biopsy in the assessment of the extent of liver disease, specifically the degree of fibrosis and the pace of progression. The emergence of these tools will have a significant impact on clinical research as well as the practice of hepatology.

Noninvasive Options for Fibrosis Assessment

The proposed methods of fibrosis assessment in a variety of liver diseases are based on clinical, biochemical, and radiologic variables and are often used in combination. Specifically, the use of serum biomarkers of fibrosis and apoptosis, and several imaging modalities to assess liver stiffness, have been introduced and validated. These noninvasive indices of liver fibrosis offer an enhanced ability to prognosticate and stratify disease, thus improving patient care; they will also inform the development of antifibrotic therapies.[5,6]

Despite this recent progress, questions remain regarding the diagnostic validity, cut-off and threshold values for the degree of fibrosis, cost, and broad applicability of each test, which should be answered with more data obtained through systematic reviews of studies.[7]


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