A decision analysis study of the value of a liver biopsy in nonalcoholic steatohepatitis

Gaidos, Jill; Hillner, Bruce E.; Sanyal, Arun J.

doi:10.1111/j.1478-3231.2008.01693.x

Cited by 69 publications

(53 citation statements)

References 39 publications

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“…A very recent study of a decision-tree model supports the use of early biopsy in the majority of cases, based on evidence from the literature and a sensitivity analysis of different scenarios, but this is not current practice in most countries. 24 This is also the reason why we could analyze only 63 cases with normal ALT, out of a large series of patients with histologically-proven NAFLD. Indications to perform liver biopsy in patients with normal ALT in participating centers were similar, including persistently increased ferritin and a long history of steatosis.…”

Section: Discussionmentioning

confidence: 99%

“…A possible limitation to this conclusion comes from the well-known sample variability in liver biopsy, which also applies to NAFLD cases. 24 However, NASH is diagnosed in the presence of fibrosis (any severity), associated with a variable degree of necroinflammation. Whereas fibrosis severity may be misdiagnosed according to sample size and chance, NASH is more likely to be underdiagnosed by sample variability.…”

Section: Discussionmentioning

confidence: 99%

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Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: A role for insulin resistance and diabetes

et al. 2008

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It is uncertain whether patients with nonalcoholic fatty liver disease (NAFLD) and normal alanine aminotransferase (ALT) have a milder disease and should undergo liver biopsy. We reviewed the histological data of 458 Italian patients with NAFLD in whom liver biopsy was indicated by altered liver enzymes (395 cases, 86%), or persistently elevated ferritin or longlasting severe steatosis (63 cases). Factors associated with nonalcoholic steatohepatitis (NASH) and fibrosis > 2 were identified by multivariate analysis. Patients with normal ALT were significantly older, had lower body mass index, fasting triglycerides, insulin resistance according to homeostasis model assessment (HOMA-IR), ALT, and gamma-glutamyltransferase, but a higher prevalence of hypertension. NASH was diagnosed in 59% and 74% of the patients with normal and increased ALT, respectively (P ‫؍‬ 0.01). In the overall series of patients, NASH was independently predicted by ALT (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.04-1.19 per 10-IU/mL increase) and diabetes (OR, 1.5; 95% CI, 1.1-2.0). The same variables were selected in patients with increased ALT, whereas in those with normal ALT, HOMA-IR and ALT were independent predictors. Severe fibrosis was independently predicted by serum ferritin (OR, 1.04; 95% CI, 1.001-1.08 per 50-ng/mL increase), ALT (OR, 1.07; 95% CI, 1.02-1.14), and diabetes (OR, 1.8; 95% CI, 1.4-2.3) in the overall series, serum ferritin and diabetes in those with increased ALT, and only HOMA-IR (OR, 1.97; 95% CI, 1.2-3.7) in patients with normal ALT. Conclusion: Normal ALT is not a valuable criterion to exclude patients from liver biopsy. Alterations in glucose metabolism and insulin resistance in subjects with normal ALT should also be considered in the selection of NAFLD cases for histological assessment of disease severity and progression. (HEPATOLOGY 2008;48:792-798.)

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: A role for insulin resistance and diabetes

et al. 2008

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“…In fact, liver biopsy is not recommended in NAFLD patients, because of its cost, the potential risk of bleeding and the absence of consensus regarding the histopatological criteria that firmly define NASH and differentiate between NAFLD entities. 47,48 Accordingly, a repeated liver biopsy after a short-term therapeutic trial is considered too invasive, especially because valid surrogate markers are available. 7 In a recent study, US showed a high sensitivity (91.7%) and specificity (100%) in detecting fatty liver 49 , and a recent review confirmed that US can accurately identify steatosis with a sensitivity and a specificity of 80-100%.…”

Section: Discussionmentioning

confidence: 99%

Metformin versus dietary treatment in nonalcoholic hepatic steatosis: a randomized study

et al. 2010

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Objective: We aimed at evaluating whether the addition of low-dose metformin to dietary treatment could be an effective approach in nondiabetic patients with nonalcoholic fatty liver disease (NAFLD). Methods: We carried out a 6-month prospective study in a series of overweight or obese patients with ultrasonographic diagnosis of hepatic steatosis. In total, 50 patients were enrolled and randomized into two groups: the first group (n ¼ 25) was given metformin (1 g per day) plus dietary treatment and the second group (n ¼ 25) was given dietary treatment alone. Results: At the end of the study, the proportion of patients with echographic evidence of fatty liver was reduced in both the metformin (Po0.0001) and the diet group (P ¼ 0.029). Moreover, patient body mass index and waist circumference significantly decreased in both groups (Po0.001). Fasting glucose, insulin resistance (evaluated as homeostasis model assessment of insulin resistance (HOMA-IR)) and serum adiponectin decreased in both groups, although these changes reached statistical significance only in the metformin group. In this group, HOMA-IR decreased from 3.3±1.6 to 2.4±1.2 (P ¼ 0.003), whereas it decreased from 3.2 ± 1.6 to 2.8 ± 1.1 (not significant, NS) in the diet group. Similarly, the proportion of patients with impaired fasting glucose declined from 35 to 5% (P ¼ 0.04) in the metformin and from 32 to 12% (NS) in the diet group. At baseline, B40% of patients in both groups met the diagnostic criteria of metabolic syndrome. This proportion decreased to 20% in the metformin group (P ¼ 0.008) and to 32% in the diet group (NS). Conclusions: In our 6-month prospective study, both low-dose metformin and dietary treatment alone ameliorated liver steatosis and metabolic derangements in patients with NAFLD. However, metformin was more effective than dietary treatment alone in normalizing several metabolic parameters in these patients.

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“…123,126 After a review of the literature, Gaidos et al 128 estimated the risk of death after liver biopsy to be around 0.01%.…”

Section: Risks Of Liver Biopsymentioning

confidence: 99%

Insulin sensitisers in the treatment of non-alcoholic fatty liver disease: a systematic review.

Shyangdan

Clar²,

Ghouri³

et al. 2011

Health Technol Assess

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A decision analysis study of the value of a liver biopsy in nonalcoholic steatohepatitis

Abstract: This decision tree model provides a context for balancing the risk and benefit of LB in NAFLD. With early biopsy, and early intervention, the relative return of preventing advanced liver disease per LB was high.

Cited by 69 publications

References 39 publications

Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: A role for insulin resistance and diabetes

Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: A role for insulin resistance and diabetes

Metformin versus dietary treatment in nonalcoholic hepatic steatosis: a randomized study

Insulin sensitisers in the treatment of non-alcoholic fatty liver disease: a systematic review.

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