title: Stepwise combination of simple noninvasive fibrosis scoring systems increases diagnostic accuracy in nonalcoholic fatty liver disease.
abstract: OBJECTIVE
  Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease ranging from simple fatty liver to steatohepatitis, fibrosis, and cirrhosis. We aimed to analyze the diagnostic performance and clinical utility of simple noninvasive tests alone or in combination for the detection of advanced fibrosis in patients with NAFLD.
  
  
  METHODS
  Data from 323 patients with biopsy-proven NAFLD/NASH who presented to the Clinic for Gastroenterology and Hepatology, University Hospital of Cologne between July 1998 and November 2009, were analyzed retrospectively. Sensitivity, specificity, positive predictive values, and negative predictive values were determined along with the area under receiver operating characteristic curves (AUROC) using published formulas for NAFLD, FIB-4, and BARD fibrosis scores.
  
  
  RESULTS
  The area under receiver operating characteristic curves were as follows: NAFLD fibrosis score 0.96 [95% confidence interval (CI), 0.92-0.99], FIB-4 0.95 (95% CI, 0.91-1.00), BARD 0.82 (95% CI, 0.71-0.92) with negative predictive values for advanced fibrosis of 96%, 98%, and 96%, respectively. When applying the NAFLD, FIB-4, or BARD scoring systems 25%, 15%, or 26% of cases with advanced fibrosis would have been missed. Combining FIB-4 and BARD in a stepwise fashion, patients would have been correctly classified without biopsy in 67% of cases without missing a single case of advanced fibrosis.
  
  
  CONCLUSIONS
  The FIB-4 and NAFLD fibrosis scores perform better than the BARD scoring system. Liver biopsy can securely be replaced only with a stepwise combination of simple noninvasive tests, otherwise the assessment of risk due to advanced fibrosis may be misleading in a clinically meaningful proportion of patients.
authors: University Hospital of Cologne, Cologne, Germany. muenevver.demir@uk-koeln.de
authors: Münevver
authors: M
authors: Demir
authors: Sonja
authors: S
authors: Lang
authors: Dirk
authors: D
authors: Nierhoff
authors: Uta
authors: U
authors: Drebber
authors: Aline
authors: A
authors: Hardt
authors: Inga
authors: I
authors: Wedemeyer
authors: Sigrid
authors: S
authors: Schulte
authors: Maria
authors: M
authors: Quasdorff
authors: Tobias
authors: T
authors: Goeser
authors: Ulrich
authors: U
authors: Töx
authors: Hans-Michael
authors: HM
authors: Steffen
mesh_terms: D000328:Adult; D001706:Biopsy; D005234:Fatty Liver / Q000175:diagnosis* / Q000473:pathology; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity