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Nonalcoholic fatty liver disease (NAFLD) has become a major public health issue. The goal of this study was to assess the clinical use of liver stiffness measurement (LSM) evaluated by supersonic shear imaging (SSI), FibroScan, and acoustic radiation force impulse (ARFI) in a cohort of NAFLD patients who underwent liver biopsy. A total of 291 NAFLD patients were prospectively enrolled from November 2011 to February 2015 at 2 French university hospitals. LSM was assessed by SSI, FibroScan (M probe), and ARFI within two weeks prior to liver biopsy. Calculations of the area under the receiver operating curve (AUROC) were performed and compared for the staging of liver fibrosis. AUROC for SSI, FibroScan, and ARFI were 0.86, 0.82, and 0.77 for diagnoses of F2; 0.89, 0.86, and 0.84 for F3; and 0.88, 0.87, and 0.84 for F4, respectively. SSI had a higher accuracy than ARFI for diagnoses of significant fibrosis ( F2) (P 5 0.004). Clinical factors related to obesity such as body mass index 30 kg/m 2 , waist circumference 102 cm or increased parietal wall thickness were associated with LSM failures when using SSI or FibroScan and with unreliable results when using ARFI. In univariate analysis, FibroScan values were slightly correlated with NAFLD activity score and steatosis (R 5 0.28 and 0.22, respectively), whereas SSI and ARFI were not; however, these components of NAFLD did not affect LSM results in multivariate analysis. The cutoff values for SSI and FibroScan for staging fibrosis with a sensitivity 90% were very close: 6.3/6.2 kPa for F2, 8.3/8.2 kPa for F3, and 10.5/9.5 kPa for F4. Conclusion: Although obesity is associated with an increase in LSM failure, the studied techniques and especially SSI provide high value for the diagnosis of liver fibrosis in NAFLD patients. (HEPATOLOGY 2016;63:1817-1827 SEE EDITORIAL ON PAGE 1762A s a result of the growing obesity epidemic, nonalcoholic fatty liver disease (NAFLD) has become a major public health issue. NAFLD currently represents the leading cause of chronic liver disease in Western countries and the second leading etiology among adults awaiting liver transplantation in the United States. (1-3) Liver-related morbidity and mortality in NAFLD patients are linked to the development of nonalcoholic steatohepatitis (NASH), which can progress to fibrosis and cirrhosis lesions. (4) NASH is also associated with an increased risk of hepatocellular carcinoma development and an increased risk of cardiovascular mortality and type 2 diabetes mellitus. (5) Liver biopsy is considered the gold Abbreviations: ARFI, acoustic radiation force impulse; AUROC, area under the receiver operating characteristics curve; BMI, body mass index; IQR, interquartile range; LSM, liver stiffness measurement; NAFLD, nonalcoholic fatty liver disease; NAS, NAFLD activity score; NASH, nonalcoholic steatohepatitis; SSI, supersonic shear imaging.

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